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INSIDE: Methods Dentists Use to Diagnose Primary Caries Lesions Prior to Restorative Treatment: Findings from The Dental PBRN — 102 Randomized Controlled Trial of a TiO2 Semiconductor Toothbrush on Mild-toModerate Periodontitis — 112 Texas Dental Journal l www.tda.org l February 2015

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TEXAS DENTAL JOURNAL Established February 1883

n

Vol 132, No 2

n

February 2015

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112

ABOUT THE COVER Star trails over Benbrook Lake in North Texas. Photo by Dean Fikar.

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METHODS DENTISTS USE TO DIAGNOSE PRIMARY CARIES LESIONS PRIOR TO RESTORATIVE TREATMENT: FINDINGS FROM THE DENTAL PRACTICE-BASED RESEARCH NETWORK JD. Brad Rindal, Valeria V. Gordan, Mark S. Litaker, James D. Bader, Jeffrey L. Fellows, Vibeke Qvist, Martha C. WallaceDawson, Mary L. Anderson, Gregg H. Gilbert The Dental Practice-Based Research Network conducts a study of diagnostic techniques dentists use before deciding to surgically treat primary caries legions.

112

RANDOMIZED CONTROLLED TRAIL OF A TIO2 SEMICONDUCTOR TOOTHBRUSH ON MILD-TO-MODERATE PERIODONTITIS. Dale W. Quest, BSN (FNP-C), PhD The author explains a study in which a toothbrush containing a titanium dioxide semiconductor was compared with a conventional toothbrush, and relays the findings of the brushes’ effects on the periodontal health of subjects.

MONTHLYFEATURES 96 98 100 122 126 134 139

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President’s Message Critically Appraised Topic of the Month Oral and Maxillofacial Pathology Case of the Month Dental Artifacts TEXAS Meeting Preview Value for Your Profession Memorial and Honorarium Donors Texas Dental Journal l www.tda.org l February 2015

139 140

In Memoriam Oral and Maxillofacial Pathology Case of the Month Diagnosis and Management 142 Calendar of Events 144 Advertising Briefs 158 Index to Advertisers

TDA members, use your smartphone to scan this QR Code and access the online Texas Dental Journal.

Editorial Staff

Editorial Advisory Board

BOARD OF DIRECTORS

Daniel L. Jones, DDS, PhD, Editor Harvey P. Kessler, DDS, MS, Associate Editor Billy Callis, Managing Editor Barbara Donovan, Art Director Paul H. Schlesinger, Consultant Nicole Scott, Consultant

Ronald C. Auvenshine, DDS, PhD Barry K. Bartee, DDS, MD Patricia L. Blanton, DDS, PhD William C. Bone, DDS Phillip M. Campbell, DDS, MSD Michaell A. Huber, DDS Arthur H. Jeske, DMD, PhD Larry D. Jones, DDS Paul A. Kennedy Jr, DDS, MS Scott R. Makins, DDS Daniel Perez, DDS William F. Wathen, DMD Robert C. White, DDS Leighton A. Wier, DDS Douglas B. Willingham, DDS

The Texas Dental Journal is a peer-reviewed publication.

Texas Dental Association 1946 S IH-35 Ste 400, Austin, TX 78704-3698 Phone: 512-443-3675 • FAX: 512-443-3031 Email: tda@tda.org • Website: www.tda.org Texas Dental Journal (ISSN 0040-4284) is published monthly (one issue will be a directory issue), by the Texas Dental Association, 1946 S IH-35, Austin, TX, 78704-3698, 512-443-3675. Periodicals Postage Paid at Austin, Texas and at additional mailing offices. POSTMASTER: Send address changes to TEXAS DENTAL JOURNAL, 1946 S IH 35, Austin, TX 78704. Copyright 2014 Texas Dental Association. All rights reserved.

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Single issue price: $6 ADA Affiliated, $17 Non-ADA Affiliated, September issue $17 ADA Affiliated, $65 NonADA Affiliated. For in-state orders, add 8.25% sales tax.

Contributions: Manuscripts and news items of interest to the membership of the society are solicited. Electronic submissions are required. Manuscripts should be typewritten, double spaced, and the original copy should be submitted. For more information, please refer to the Instructions for Contributors statement printed in the September Annual Membership Directory or on the TDA website: tda.org. All statements of opinion and of supposed facts are published on authority of the writer under whose name they appear and are not to be regarded as the views of the Texas Dental Association, unless such statements have been adopted by the Association. Articles are accepted with the understanding that they have not been published previously. Authors must disclose any financial or other interests they may have in products or services described in their articles.

Advertisements: Publication of advertisements in this journal does Association of not constitute a guarantee or endorsement by the Association of Dental Editors and the quality of value of such product or of the claims made of it by Journalists. its manufacturer.

PRESIDENT Craig S. Armstrong, DDS 832-251-1234, drarmstrong01@gmail.com PRESIDENT-ELECT Arthur C. Morchat, DDS 903-983-1919, amorchat@suddenlink.net IMMEDIATE PAST PRESIDENT David A. Duncan, DDS 806-355-7401, davidduncandds@gmail.com VICE PRESIDENT, NORTHEAST Jerry J. Hopson, DDS 903-583-5715, dochop@verizon.net VICE PRESIDENT, SOUTHEAST William S. Nantz, DDS 409-866-7498, wn3798@sbcglobal.net VICE PRESIDENT, SOUTHWEST Joshua A. Austin, DDS 210-408-7999, jaustindds@me.com VICE PRESIDENT, NORTHWEST Steven J. Hill, DDS 806-783-8837, sjhilldds@aol.com SENIOR DIRECTOR, NORTHEAST William H. Gerlach, DDS 972-964-1855, drbill@gerlachdental.com SENIOR DIRECTOR, SOUTHEAST Karen A. Walters, DDS 713-790-1111, kwalters@sms-houston.com SENIOR DIRECTOR, SOUTHWEST John B. Mason, DDS 361-854-3159, jbmasondds@aol.com SENIOR DIRECTOR, NORTHWEST Charles W. Miller, DDS 817-572-4497, cwdam@sbcglobal.net DIRECTOR, NORTHEAST Dennis E. Stansbury, DDS 903-561-1122, drstansbury@gmail.com DIRECTOR, SOUTHEAST Duc “Duke” M. Ho, DDS 281-395-2112, ducmho@sbcglobal.net DIRECTOR, SOUTHWEST James R. Foster, DDS 956-969-2727, fosterdds@gmail.com DIRECTOR, NORTHWEST W. Kurt Loveless, DDS 806-797-0341, wklovedds@gmail.com SECRETARY-TREASURER* Ron Collins, DDS 281-983-5677, roncollinsdds@yahoo.com SPEAKER OF THE HOUSE* John W. Baucum III, DDS 361-855-3900, jbaucum3@gmail.com EDITOR** Daniel L. Jones, DDS, PhD 214-828-8350, djones@bcd.tamhsc.edu *Non-voting member **Non-member attendee

Texas Dental Journal l www.tda.org l February 2015

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WHO WE ARE: We are licensed and practicing dentists in Texas, and we understand your needs. While other providers are in the process of contemplating program development, our courses have met the ADA Guidelines for more than 10 years. The new anesthesia guidelines were recently approved by the Texas State Board of Dental Examiners. As practicing dental anesthesiologists and educators, we have established continuing education programs to meet these needs.

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McKinney, Texas: Credit: Time:

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Friday, March 27, 2015; Friday, May 8, 2015 TBA Saturday, May 9, 2015 8 hours lecture 7:30 am – Registration; 8:00 am – Presentation start time

Pediatric and Adult Protective Stabilization Course (PAPS©):

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Houston, Texas: Friday and Saturday, June 12-13, 2015 Credit: 16 hours lecture for 2-day program; or 8 anesthesia hours for 1 day program Time: 7:30 am – Registration; 8:00 am – 5:00 pm – Presentation *This initial ACLS or PALS course requires a prerequisite that must be completed online prior to the live program.

AGD Codes for all programs: 341 Anesthesia & Pain Control; 342 Conscious Sedation; 343 Oral Sedation

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President’s Perspective Craig S. Armstrong, DDS, TDA President

T

his February, we are lucky to have National Children’s Dental Health Month, Legislative Day, and a new TDA social media campaign.

I don’t need to tell you that the best thing about being a dentist is making your patients smile, and knowing you’ve made them healthy and happy.

And few things are more rewarding than helping a young patient get started on the road to a lifetime of good oral health.

Held each legislative session, Legislative Day gives TDA members a chance to work with the state’s legislative officials, to help shape the future of dentistry.

The ADA sponsors National Children’s Dental Health Month (NCDHM) each February. This year’s theme is “Defeat Monster Mouth.” Look for the each February. This year’s theme was “Defeat Monster Mouth.” Look for the ADA’s “Defeat Monster Mouth” poster in the most recent issue of TDA’s patient publication, Smart Mouth, which arrived with your December issue of the Texas Dental Journal.

February 6 was designated as this year’s Give Kids a Smile (GKAS) day, but February 6 is designated as this year’s Give Kids a Smile (GKS) day, but dentists are encouraged to hold a GKS event any time of the year. To date, dentists are encouraged to hold a GKAS event any time of the year. To date, 1,395 GKAS events have already been held in 2015, serving an estimated 326,535 children, with 7,985 dentists participating. Involvement in NCDHM is a great way for dentists to reach families, and show how much they care about the oral health of their youngest patients.

Held each legislative session, Legislative Day gives TDA members a chance to work with the state’s legislative officials, to help shape the future of dentistry. TDA members’ advocacy and involvement in the legislative process is what allows dentists to provide the best care to our patients.

This year, Legislative Day was is February February 25.25.

As we celebrate National Children’s Dental Health Month and engage with withlegislative our our legislative officials, officials, TDA has TDAalso is also implemented implementing a new a new social social media media strategy, beginning in February. Social media is key in connecting with the younger generation of dentists, reaching new members, and staying timely in a world of instant communication and constant change. Our social media campaign will also include useful and educational content for the general public, and will educate patients on oral health and on the importance of choosing a TDA member dentist. Do you want to stay in the loop? Please like the TDA Facebook page at facebook.com/ TexasDentalAssociation and follow us on twitter@theTDA. twitter @theTDA. February is a starting point for all of these. Not only this month, but throughout the year, I challenge and encourage you to engage with your community, with those who shape legislation, and with the TDA.

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Texas Dental Journal l www.tda.org l February 2015

David Faltys is currently a Junior Dental Student at UT Health Science Center.

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Texas Dental Journal l www.tda.org l February 2015

John “JR� Roberts, DDS, is the State Dental Director with Texas Dept. of Aging and Disability Services State-Supported Living Center.

Maria-Jose Cervantes Mendez, DDS, is currently an Assistant Professor and Director of the Pediatric Dentistry Graduate Program in the Dept. of Developmental Dentistry at UT Health Science Center.

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Oral and Maxillofacial Pathology Case of the Month Case: A 13-year-old male presented for consultation to an orthodontic office with slight swelling of his left mandibular ramus and body (Figure 1). He was asymptomatic and did not report any pain or discomfort in the involved region. He had been diagnosed with autism spectrum disorder and was taking Prozac for anxiety and Daytrana patch for ADHD. Panoramic radiographic examination was performed and revealed bilateral multilocular radiolucencies involving the mandible. The lesions were large and extended to involve the retromolar region, the ramus and angle of the mandible. The lesions did not involve either of the condyles (Figure 2). An incisional biopsy was performed and revealed bland spindle cells in a stroma with multinucleated giant cells (Figures 3 and 4) and blood vessels showing perivascular cuffing.

Bone fragments or evidence of bone invasion were not evident in the submitted specimen.

Bhattacharya

John M Wright, DDS, MS, diagnostic sciences, Texas A&M University Baylor College of Dentistry, Dallas, Texas Richard Reza Hadavand, DDS, private practice, Orthodontics, McKinney, Texas

Figure 2.

Figure 3.

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Texas Dental Journal l www.tda.org l February 2015

Hadavand

Aditi Bhattacharya, BDS, MDS, PhD

What is your diagnosis? See page 138 for the diagnosis and answer.

Figure 1.

Wright

Figure 4.

the

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Texas TexasDental DentalJournal Journal l l www.tda.org www.tda.org l l February February2015 2015 101 101

TDA is an ADA CERP Provider

Methods dentists use to diagnose primary caries lesions prior to restorative treatment: Findings from The Dental PBRN About the Authors D. Brad Rindal, HealthPartners Dental Group, Minneapolis, MN, HealthPartners Research Foundation, 8170 33rd Ave S, M.S. 21111R, Minneapolis, MN. CORRESPONDING AUTHOR: Tel.: +1-952-967-5026; fax: +1-952-967-5022.

Email address: Donald.B.Rindal@HealthPartners.com. dpbrn.org/users/publications/default.aspx (1). available at sciencedirect.com. journal homepage: intl.elsevierhealth.com/journals/jden0300-5712/$ — see front matter # 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.jdent.2010.09.003 Valeria V. Gordan, Department of Operative Dentistry, School of Dentistry, University of Florida, Gainesville, FL. Mark S. Litaker, Department of General Dental Sciences, School of Dentistry, University of Alabama, Birmingham, AL. James D. Bader, Department of Operative Dentistry and the Cecil Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC. Jeffrey L. Fellows, Kaiser Permanente Center for Health Research, Portland, OR. Vibeke Qvist, Department of Cariology and Endodontics, Royal Dental College, Copenhagen, Denmark.

Martha C. Wallace-Dawson, Private Practitioner in Birmingham, AL. Mary L. Anderson, HealthPartners Dental Group, Minneapolis, MN. Gregg H. Gilbert, Department of General Dental Sciences, School of Dentistry, University of Alabama, Birmingham, AL. For The DPBRN Collaborative Group, which includes practitioner-investigators, faculty investigators, and staff investigators who contributed to this activity.

ACKNOWLEDGMENTS: The authors acknowledge grants U01-DE-16746 and U01DE-16747 from the National Institutes of Health. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health. The informed consent of all human subjects who participated in this investigation was obtained after the nature of the procedures had been explained fully.

CONFLICT OF INTEREST: None of the authors declare any conflicts of interest.

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JD. Brad Rindal, Valeria V. Gordan, Mark S. Litaker, James D. Bader, Jeffrey L. Fellows, Vibeke Qvist, Martha C. Wallace-Dawson, Mary L. Anderson, Gregg H. Gilbert Reprinted from Journal of Dentistry, 38/2010, D. Brad Rindal et al, Methods dentists use to diagnose primary caries lesions prior to restorative treatment: Findings from The Dental PBRN, 1027-1032, ©2015 with permission from Elsevier.

Introduction

D

etection of caries lesions is crucial to their prevention and treatment (1). The ideal method of detection accurately measures the depth of the caries process, which is important in monitoring progression of active lesions and in making clinical decisions (2). Our current understanding of the caries process provides clinicians with treatment options to arrest or re mineralize early lesions (3). If the lesion has progressed to cavitation, it is not amenable to re mineralization and requires a restoration (4).

However, the widespread use and availability of fluoride has dramatically slowed the progression of carious lesions such that dentists typically detect caries at an earlier stage.

In view of these changes, accurate caries detection has a critical impact on treatment decisions; incorrect

Texas Dental Journal l www.tda.org l February 2015

diagnosis may result in incorrect treatment decisions, particularly with respect to operative intervention (5).

Variation amongst dentists in the identification and depth estimation of caries lesions is well-known, mostly from studies of ‘‘cases’’ prepared by investigators. There have been few assessments of the detection techniques being used by dentists in clinical practice (6–14). To learn more, we need to examine how clinicians identify lesions in their practices.

This study is a component of a broader research program being undertaken by ‘‘The Dental PracticeBased Research Network’’ (DPBRN, dpbrn.org) to investigate how dentists diagnose and treat dental caries (15–19). DPBRN is a consortium of dental practices with a broad representation of practice types and treatment philosophies that conducts research across geographically

dispersed regions. The objectives of this study are (1) to quantify the diagnostic techniques used by DPBRN practitioner-investigators before they decide to treat primary caries lesions surgically, and (2) to examine whether certain dentist, practice, and patient characteristics are associated with the use of these techniques.

Materials and methods Selection and recruitment process Practitioner-investigators from DPBRN who perform restorative dentistry in their practices were enrolled in this study. DPBRN comprises 5 regions: Alabama/Mississippi (AL/MS), Florida/Georgia (FL/GA), Minnesota dentists employed by HealthPartners Dental Group or practicing in the community (MN), Permanente Dental Associates in cooperation with Kaiser Permanente’s Center for Health Research (PDA), and Denmark, Norway, and Sweden (SK) (15).

Practitioner-investigators in DPBRN were recruited into the network through continuing education courses and mass mailings to licensed dentists from the participating regions. As part of enrollment in DPBRN, all practitioner-investigators complete a DPBRN Enrollment Questionnaire about themselves and their practice characteristics. As part of eligibility for this particular study, all dentists completed (1) the Enrollment Questionnaire, (2) an Assessment of Caries Diagnosis and Caries Treatment Questionnaire, (3) training in human subjects protection, and (4) a training session with a DPBRN staff 20 regional coordinator assigned to their practice.

This training session discussed in detail the study protocol, data collection forms, and related details.

Additional requirements varied by DPBRN region and are described elsewhere (21). These questionnaires are publicly available on the DPBRN Supplement page (22).

Study design This cross-sectional study used a consecutive patient/restoration recruitment design. Once the study was started in a practice, every patient scheduled to have a restoration on a previously unrestored permanent tooth surface was asked to participate until 50 patients had been enrolled or

Abstract Objective: To (1) quantify the diagnostic techniques used by Dental PracticeBased Research Network (DPBRN) dentists before they decide to treat primary caries lesions surgically and (2) examine whether certain dentist, practice, and patient characteristics are associated with their use.

Methods: A total of 228 DPBRN dentists recorded information on 5,676 consecutive restorations inserted due to primary caries lesions on 3,751 patients. Practitioner-investigators placed a mean of 24.9 (SD = 12.4) restorations. Lesions were categorized as posterior proximal, anterior proximal, posterior occlusal, posterior smooth, or anterior smooth. Techniques used to diagnose the lesion were categorized as clinical assessment, radiographs, and/or optical. Statistical analysis utilized generalized mixedmodel ANOVA to account for the hierarchical structure of the data.

Results: By lesion category, the diagnostic technique combinations used most frequently were clinical assessment plus radiographs for posterior proximal (47%), clinical assessment for anterior proximal (51%), clinical assessment for posterior occlusal (46%), clinical assessment for posterior smooth (77%), and clinical assessment for anterior smooth (80%). Diagnostic technique was significantly associated with lesion category after adjusting for clustering in dentists (p < 0.0001).

Conclusion: These results — obtained during actual clinical procedures rather than from questionnaire-based hypothetical scenarios — quantified the diagnostic techniques most commonly used during the actual delivery of routine restorative care. Diagnostic technique varied by lesion category and with certain practice and patient characteristics.

Key Words Dental caries, dentists’ practice patterns, diagnostic techniques and procedures

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a certain date had passed. If patients had multiple appointments during the study period, data were collected only at the first appointment. To broaden enrollment, we limited the number of eligible restorations to 4 during the patientâ&#x20AC;&#x2122;s first appointment in the study period. A consecutive patient/restoration log form was used to record information on eligible restorations regardless of whether the patient participated in the study. All of the data collection forms used for this study is available on the DPBRN Supplement page (dentalpbrn.org/ users/publications/supplement.aspx).

The survey was pilot-tested to assess the feasibility and comprehension of each questionnaire item (23).

We collected data for: (a) patient race, Hispanic/Latino ethnicity, sex, and age; (b) tooth number, surface, and primary reason for placement of the restoration (ie, primary caries or noncarious defect); and (c) techniques used to diagnose the primary caries (ie, probing, radiographs, transillumination, or optical technique such as DIAGNOdent). This study also collected data on preoperative depth, postoperative depth, and restorative materials placed. The latter results are not presented here; we limited our analyses to carious lesions involving only one surface. We considered multi surface categories, but the number of lesions in each category was small, limiting our ability to draw meaningful conclusions.

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Dentist-level and practice-level variables Dentist-level variables were available from the DPBRN Enrollment Questionnaire. In addition to DPBRN region, DPBRN dentists can also be characterized by type of practice (ie, solo or small group private practice [SGP], large group practice [LGP], or public health practice [PHP]). SGPs were defined as having no more than 3 dentists. LGPs were defined as having 4 or more dentists. PHPs were defined as receiving most of their funding from public sources. In the AL/MS region, 98% of practitionerinvestigators were in SGPs, and 2% were in PHPs. In the FL/GA region, 97% were in SGPs, and 3% were in PHPs. In the MN region, 90% were in LGPs, and 10% were in SGPs. In the PDA region, all were in LGPs. In the SK region, 64% were in SGPs, and 36% were in PHPs. The dentistâ&#x20AC;&#x2122;s year of graduation from dental school, gender, and ethnicity were also available. Dentists were given several choices to describe their workload during the past year.

Patient-level variables For each enrolled patient, data were collected about the patientâ&#x20AC;&#x2122;s gender, age, race, Hispanic or Latino ethnicity, and any dental insurance or thirdparty coverage.

Statistical analysis Our primary statistical analytic approach used generalized linear models (GLM) implemented with generalized estimating equations (GEE) in SAS1 PROC GENMOD software to conduct analysis of variance (ANOVA) and logistic regression analysis, accounting for

Texas Dental Journal l www.tda.org l February 2015

correlations amongst observations due to the hierarchical structure of the data/clustering. A generalized estimating equations approach to logistic regression was used to model the associations between use of diagnostic technique and dentist-, practice-, and patient-level characteristics whilst simultaneously accounting for within-dentist, within-practice, and within-patient clustering. This clustering is due to the fact that dentists/practices enrolled numerous patients from the same practice (within-dentist clustering), and patients could have had as many as four restorations during the study (within-patient clustering).

Diagnostic method use showed a median intra-class correlation coefficient (ICC) of 0.22 for clustering by dentist and practice, and 0.54 for clustering by patient within dentist and practice; accounting for the effect of clustering was essential to the validity of the statistical models.

Maximum-likelihood estimates of ICCs were obtained from the GEE working correlation matrices. Ordinarily, bivariate cross-tabulations done as in Tables 2 and 3 would be tested for statistical significance using c2 tests and Mantel-Haenszel c2 trend tests.

However, this was not appropriate in this context because of the withinclass clustering. Therefore, statistical tests in Table 4 were done using GEEbased logistic regressions to account for the effect of this clustering.

Lesions were classified into 5 categories on the basis of the surfaces identified as involved in the restoration (ie, posterior proximal, anterior proximal, posterior occlusal, posterior smooth surface, and

anterior smooth surface). Frequencies of use of each of the techniques were tabulated by surface classification and region for all restorations. Because more than one technique could be specified, and more than a single surface could be included in a single restoration, these counts are not mutually exclusive. GEE-based ANOVA was used to compare rates of use of the diagnostic techniques amongst regions and surface classifications.

GEE logistic regression was conducted to identify predictors of use of each of the diagnostic techniques.

These analyses were restricted to restorations classified into a single surface category. Modelling was conducted separately for each of the diagnostic techniques.

Model selection was conducted within two blocks of potential predictors, representing practitioner- and practice-level variables and patientlevel variables (1,2). Practitioner level variables included region, gender, years since graduation from dental school (<5, 5â&#x20AC;&#x201C;15, 15â&#x20AC;&#x201C;20, >20), type of practice (SGP, LGP, or PHP), and whether caries risk assessment is routinely conducted (no or no response; yes, no form used or not known if form was used; yes, using form). Patient-level variables considered were age, gender, race (white, black, American Indian/Alaska native, Asian, native Hawaiian/other Pacific islander, other), ethnicity (Hispanic/Latino, not), and whether the patient had dental insurance.

Within each block, separate analyses were conducted for each potential predictor variable. Variables showing

significant association at p < 0.10 with use of a technique were then included in a multiple logistic regression model.

Variables that were significant at p < 0.10 in either of the block-level multivariable models were included in a final predictive model for the respective diagnostic technique to avoid excluding variables that might become more significant in the multivariable model.

Results Ninety-five percent of eligible consecutive patients enrolled in the study. Table 1 shows the percentage of use of the different methods of diagnosis, alone or in combination with the other techniques, by lesion location. Diagnostic technique was significantly associated with lesion location after adjusting for clustering

Table 1. Diagnostic techniques used overall and by lesion location (limited to restorations that were done because of a caries lesion on one surface only).

Clinical assessment only Radiographs only Optical only Clinical assessment + radiographs Clinical assessment + optical

Posterior proximal 138 (8.8%) 637 (40.4%) 2 (.01%) 740 (47.0%)

Anterior proximal

Posterior occlusal

Posterior smooth

Anterior smooth

225 (50.5%) 993 (46.3%) 747 (76.8%) 295 (79.5%) 35 (7.9%)

74 (3.5%)

12 (1.2%)

11 (3.0%)

11 (2.5%)

19 (0.9%)

2 (0.2%)

1 (0.3%)

128 (28.7%) 886 (41.3%) 194 (19.9%)

57 (15.4%)

4 (0.3%)

26 (5.8%)

103 (4.8%)

10 (1.0%)

6 (1.6%)

Radiographs + optical

27 (1.7%)

9 (2.0%)

15 (0.7%)

7 (0.7%)

0 (0.0%)

All three

28 (1.8%)

12 (2.7%)

57 (2.7%)

1 (0.1%)

1 (0.3%)

Total 1576 (100%) 446 (100%) 2147 (100%) 993 (100%) 371 (100%)

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in dentists (p < 0.0001). Radiographs plus clinical assessment (47%) and radiographs alone (40%) were used most commonly to detect posterior proximal caries. Clinical assessment (51%) and clinical assessment plus radiographs (29%) were the most common detection method for anterior proximal caries. Clinical assessment only (46%) and clinical assessment plus radiographs (41%) were the most common approaches for occlusal surfaces. Clinical assessment only was used by the large majority of dentists to detect

caries on posterior (77%) and anterior smooth surfaces (80%).

model for transillumination or optical technique.

Dentist and practice characteristics potentially associated with the use of each diagnostic technique were first analyzed in a univariate model (Table 2). Variables associated at p < 0.10 were included in the final model.

Thus, practice type, use of caries risk assessment, and region were included in the final model for clinical assessment; practice type and region in the model for radiographs; and use of risk assessment and region in the

Patient characteristics that were evaluated for association with the use of a diagnostic technique are presented in Table 3. For clinical assessment, patient age and ethnicity were included in the final model; for radiographs, patient age and insurance coverage were included; and for transillumination or optical technique, patient gender was included.

Table 2. Association (p value) of dentist and practice characteristics with use of diagnostic technique in one variable models.

Characteristic

Clinical assessment Years since graduation Gender of dentist Race/ethnicity of dentist Practice type (solo, group, public) Caries risk assessment Region

0.2307 0.1135 0.5893 0.0187 0.0531 0.0017

p value Radiograph

Transillumination or optical technique

0.4687 0.1304 0.2984 0.9965 0.5127 Note 0.0007 0.1358 0.1125 0.0159 0.0010 0.0337

Note: Estimation algorithm failed. Dentist race distribution is sparse (88.8% white) and relatively small number (341) of uses of optical technique (307 of which were done by white dentists).

Table 3. Association (p value) of patient characteristics with use of diagnostic technique in one variable models.

Characteristic

Clinical assessment Age Gender Race Ethnicity Insurance

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0.0529 0.9231 0.8150 0.0022 0.8411

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p value Radiograph

Transillumination or optical technique

<0.0001 0.7822 0.3633 0.2707 0.1094

0.5783 0.0633 0.6636 0.9742 0.3852

Patient, dentist, and practice characteristics included in the multiple logistic regression model are presented in Table 4. Regional differences were detected in the use of clinical assessment (p = 0.0021) and radiographs (p = 0.0007). The AL/MS and FL/GA regions rely more on clinical assessment and less on radiographs than other regions. We also saw an association of region (p = 0.0189) and use of transillumination or optical technique. The overall use of optical technique was low (used to detect 371 lesions), and the results are difficult to summarize because of differences in cluster size.

Patient variables associated with the use of diagnostic technique include age (p < 0.0001, for radiograph), ethnicity (p = 0.0023, for clinical assessment), and dental insurance (p = 0.0449, for radiograph). Older patients are less likely to receive radiographs. Clinical assessment

was listed for 91.5% of restorations in Hispanic patients vs. 81.9% of restorations in non-Hispanic patients.

Patients with dental insurance are less likely to receive radiographs.

Discussion These results further illuminate the diagnostic techniques used by dentists in daily practice to detect initial caries on a previously unrestored surface.

They also provide insight into patient and provider characteristics that may influence the use of these techniques.

Regional differences in the application of the clinical assessment would suggest differences in training and accepted standards of care. We need to be careful in drawing conclusions about the use of transillumination or optical techniques, because they are used infrequently and usually in combination with other techniques.

Use of radiographs is related to DPBRN region, age of the patient, and dental insurance benefits. It is possible that older patients have a longer dental history for the dentist to consider when deciding if a radiograph is needed to detect caries in areas not observed visually.

Dental insurance determines the cost to the patient for radiographs; the counter intuitive observation that patients with dental insurance are less likely to receive radiographs suggests that benefit limitations common to dental insurance policies may influence provider and patient decisions regarding radiographs. The regional differences might be related to teaching and peer norms regarding the prescribing of radiographs.

Clinical assessments and radiographs continue to be the primary caries detection methods employed by dentists in daily practice. Despite the marketing of diagnostic tools such as

Table 4. Association of dentist, practice, and patient characteristics with use of diagnostic technique in final models (only statistically significant p values are provided).

Characteristic Years since graduation from dental school Gender of dentist Practice type (SGP, LGP, PHP) Dentist uses caries risk assessment Region Patient age Patient gender Patient race Patient ethnicity Whether patient has dental insurance

Clinical assessment Radiograph Transillumination or optical technique

0.0021

0.0007 <0.0001

0.0023

0.0449

0.0189 0.0671

LGP: large group practice; PHP: public health practice; SGP: small group practice.

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DIAGNOdent, they are used at very low rates by dentists enrolled in The DPBRN. As new diagnostic techniques become available in the future, practice-based research networks will afford us the opportunity to examine their adoption in daily practice. A recent systematic review of current evidence presented in the literature concluded that utilization of a combination of visual-tactile and radiographic evidence is still the best caries diagnostic technique. Current practice is consistent with current evidence (23).

Conclusion These results — obtained during actual clinical procedures rather than from questionnaire-based hypothetical scenarios — quantified the diagnostic techniques most commonly used by practicing dentist in real-world setting during the actual delivery of routine restorative care.

We identified significant regional differences in the utilisation of the various diagnostic techniques. These regional differences may be due to differences in dental education and community practice norms. Patient age, gender and having dental insurance are also associated with the use of diagnostic technique.

3.

4.

5.

6.

7.

8.

REFERENCES 1. Bader JD, Shugars DA. A systematic review of the performance of a laser fluorescence device for detecting caries. Journal of American Dental Association 2004; 135:1413–26.

2. Pitts NB. Modern concepts of caries measurement. Journal of

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Dental Research 2004;83(Spec.

No. C):C43–7.

Bader JD, Shugars DA. The evidence supporting alternative management strategies for early occlusal caries and suspected occlusal dentinal caries. Journal of Evidence Based Dental Research 2006;6:91–100.

Pitts NB, Stamm JW. International Consensus Workshop on Caries Clinical Trials (ICW-CCT)—final consensus statements: agreeing where the evidence leads. Journal of Dental Research 2004;83(Spec.

No. C):C125–C128.

Zandona AF, Zero DT. Diagnostic tools for early caries detection.

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Lewis DW, Pharoah MJ, ElMowafy O, Ross DG. Restorative certainty and varying perceptions of dental caries depth among dentists. Journal of Public Health Dentistry 1997; 57:243–5.

El-Mowafy OM, Lewis DW. Restorative decision making by Ontario dentists. Journal of the Canadian Dental Association 1994;60:305–10. 13–16.

Winn DM, Brunelle JA, Selwitz RH, Kaste LM, Oldakowski RJ, Kingman A, et al. Coronal and root caries in the dentition of adults in the United States, 1988– 1991. Journal of Dental Research 1996;75(Spec. No.):642–51.

Mettes TG, van der Sanden WJ, Mokkink HG, Wensing M, Grol RP, Plasschaert AJ. Routine oral examinations in primary care: which predictors determine what is done? A prospective clinical case recording study. Journal of Dentistry 2008;36:435–43.

10. Gilbert GH, Bader JD, Litaker MS, Shelton BJ, Duncan RP. Patient-level and practice-level characteristics associated with receipt of preventive dental services: 48-month incidence.

Journal of Public Health Dentistry 2008; 68:209–17.

11. Gilbert GH, Weems RA, Litaker MS, Shelton BJ. Practice characteristics associated with patient-specific receipt of dental diagnostic radiographs. Health Services Research 2006;41:1915– 37.

12. Domejean-Orliaguet S, Leger S, Auclair C, Gerbaud L, TubertJeannin S. Caries management decision: influence of dentist and patient factors in the provision of dental services. Journal of Dentistry 2009;37:827–34.

13. Zadik Y, Levin L. Clinical decision making in restorative dentistry, endodontics, and antibiotic prescription. Journal of Dental Education 2008;72:81–6.

14. Mettes TG, van der Sanden WJ, Mokkink HG, Wensing M, Grol RP, Plasschaert AJ. Routine oral examination: clinical performance and management by general dental practitioners in primary care. European Journal of Oral Sciences 2007;115:384–9.

15. Gilbert GH, Williams OD, Rindal DB, Pihlstrom DJ, Benjamin PL, Wallace MC. The creation and development of The Dental Practice-Based Research Network. Journal of American Dental Association 2008;139: 74–81.

16. Makhija SK, Gilbert GH, Rindal DB, Benjamin P, Richman JS, Pihlstrom DJ, et al. Practices participating

in a dental PBRN have substantial and advantageous diversity even though as a group they have much in common with dentists at large. BioMed Central Oral Health 2009;9:26.

17. Gordon VV, Bader JD, Garvan CW, Richman JS, Qvist V, Fellows JL, et al. Restorative treatment thresholds for occlusal primary caries by dentists in The Dental Practice-Based Research Network.

Journal of the American Dental Association 2010;141(2):171–84.

18. Gordon V, Garvan C, Heft M, Fellows J, Qvist V, Rindal DB, et al.

Restorative treatment thresholds for interproximal primary caries based on radiographic images: findings from The Dental PBRN.

General Dentistry 2009;57:654– 63. 19. Nascimento MM, Gordon VV, Mjör IA, Qvist V, Litaker MS, Williams OD, et al. Reasons for placement of restorations on previously unrestored tooth surfaces by dentists in The Dental Practice-Based Research Network.

Journal of the American Dental Association 2010;141(4):441–8.

20. Gilbert GH, Qvist V, Moore SD, Rindal DB, Fellows JL, Gordan VV, et al. Institutional review board and regulatory solutions in The Dental PBRN. Journal of Public Health Dentistry 2009.

21. Supplements to specific DPBRN publications. Dental PracticeBased Research Network. http:// www.dentalpbrn.org/users/

publications/Supplement.aspx [accessed 09.10].

22. Gordan VV, Garvan CW, Heft MW, Fellows JL, Qvist V, Rindal DB, et al. Restorative treatment thresholds for interproximal primary caries based on radiographic images: findings from the Dental Practice-Based Research Network. General Dentistry 2009;57:654–63. [quiz 64-6, 595, 680].

23. Ewoldsen N, Koka S. There are no clearly superior methods for diagnosing, predicting, and noninvasively treating dental caries. Journal of Evidence Based Dental Research 2010;10:16–7.

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Randomized controlled trial of a TiO2 Semiconductor toothbrush on mild-to-moderate periodontitis.

Dale W. Quest, BSN (FNP-C), PhD

Abstract

About the Author Dale W. Quest, BSN (FNP-C), PhD, associate professor, Department of Medical Education, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center – El Paso, Medical Education Bldg. Suite 2200, Office H 5001 El Paso Dr, El Paso, Texas 79905 – 2827 email: dale.quest@ttuhsc.edu Telephone: office 915-215-4346 cellular 915-449-7544 facsimile 915-783-1715 Support: Unrestricted funding and supply of active and inert toothbrushes for this study was provided

by SHIKEN Co, Ltd, Osaka, Japan.

The author has no declared potential conflicts of financial interest, relationships and/or affiliations relevant to the subject matter or the materials discussed in the manuscript.

This manuscript has been peer reviewed.

The Soladey™ toothbrush (Shiken Corp., Osaka, Japan) is based on the principle that electrical induction will cause a wetted titanium dioxide semiconductor to emit electrons. The manufacturer claims that in addition to the established mechanical benefits of brushing, the flow of electrons from the brush head may disrupt ionic bonding of plaque, neutralize bacterial organic acids, and thus confer an advantage over a conventional toothbrush.

AIM: Determine whether a TiO2 semiconductor-containing toothbrush confers an advantage over a conventional toothbrush in adult patients with mild-to-moderate gingivitis/periodontitis.

MATERIALS and METHODS: Seventy-one patients with mild-to-moderate gingivitis/periodontitis were enrolled in this randomized, double-blind, placebo-controlled modified crossover trial that compared the Soladey-3 titanium dioxide semiconductor toothbrush (Shiken Corp., Osaka, Japan) to an otherwise identical toothbrush containing an inert resin core in place of the semiconductor. Changes in indices of gingivitis and periodontitis were the primary outcomes.

RESULTS: Sixty-six patients completed the study. Relative to baseline, an almost two-fold increased gingival crevice fluid flow followed both active and control treatments was statistically significant. Relative to the inactive control device, the active Soladey-3 toothbrush had no clinically meaningful effects on selected markers of gingivitis/periodontitis.

CONCLUSIONS: The active Soladey-3 toothbrush did not substantially impact selected markers of gingivitis/periodontitis by the end of a two-week treatment period in adult patients with mild-to-moderate disease. Both inactive (control) and active (TiO2 semi-conductor) versions of the Soladey toothbrushes significantly increased crevice fluid flow.

Key Words toothbrush, ionic toothbrush, titanium dioxide semiconductor

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Introduction Organic acid-producing anaerobic bacteria are implicated in the development and progression of gingivitis and periodontal disease (1). The disease process manifests as periodontal inflammation and tissue destruction (2). The Soladey-3 toothbrush is an application of the definition established by the American chemist G.N. Lewis in 1923, that an acid is an electron-pair acceptor (Figure 1). In addition to the established mechanical benefits of brushing, the flow of electron pairs for neutralizing bacterial organic acids and disrupting plaque may confer an advantage over a conventional toothbrush. There is some evidence that the electrons may also interact

with bacterial coenzyme-A to have an antibacterial effect (3). The bactericidal effect of the light activated TiO2 semiconductor added to Streptococcus mutans cultures has been demonstrated in vitro (4).

A 2-way crossover clinical trial of the Soladey toothbrush involving 73 children aged 13 to 15 years, reported significantly greater removal of plaque from buccal surfaces over a period of 3 weeks, compared to a similar toothbrush without the TiO2 semiconductor (5). Another study divided 60 adult female dental hygiene students into 2 groups to compare the TiO2 semiconductor toothbrush to a conventional toothbrush on the basis of the Snyder test for lactobacillus activity, Salivaster test for occult blood, the PMA-1 test

for gingivitis, the Quigley-Hein Plaque Index, and the WHO Community Periodontal Index of Treatment Needs (CPITN). Both groups used the respective toothbrushes with standardized toothpaste for a period of 3 weeks. A trend in PMA-1 favoring the active toothbrush gradually reached significance by the end of the third week. No significant differences were observed in the other outcomes (6). In 12 adults with good oral health status at the outset, brushing twice-daily with the TiO2 semiconductor toothbrush correlated with lower plaque scores at 1 week and 1 month, compared sequentially to an otherwise identical toothbrush without the TiO2 semiconductor, then a conventional toothbrush (7).

Figure 1. Soladey-3 toothbrush appearance and proposed mechanism of action

Detachable brush head with TiO2 core handle solar electric generator. Reproduced with permission: Soladey International.

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Figure 2.

Soladay-3 Study Design Arm “A”

Arm “B”

Arm “C”

Study Population: Clinic patient volunteers (female and male, age 30 to 75 years) consenting subjects with early periodontitis (mild to moderate, gingivitis index: 1 to 2).

AB:

B BC C CD: D: DE: E

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Recruitment and screening of patients: Dental history documented current dental hygiene practice pattern (brushing, flossing, type of toothpaste, type of mouthwash). Each subject was asked to maintain that pattern during their participation in this study.

Baseline #1 data collection, random allocation of subject to treatment arm according to scheme, dispense toothbrush and follow-up instructions.

First treatment period = 14 days.

End of first treatment period: post-treatment data collection.

Washout period = 14 days; dispense toothbrush and follow-up instructions to enter cross-over treatment arm.

Second treatment period baseline #2 data collection.

Second treatment period = 14 days.

End of second treatment period: post-treatment data collection, exit subjects to clinic recall roster.

Texas Dental Journal l www.tda.org l February 2015

Materials and Methods Human Subjects This study was conducted in full accordance with ethical principles, including the World Medical Association Declaration of Helsinki (version VI, 2002). Participation was conditioned upon initial and ongoing free and informed consent of each participant. The protocol underwent prospective review and obtained University of Saskatchewan Biomedical Research Ethics Board Approval (Bio-REB 05-20). Health Canada Class II Medical Device Investigational Testing Authorization was obtained (number 94853). The ClinicalTrials.gov Protocol Registration System Identifier is NCT00167466.

Potential subjects were identified through the University Dental Clinic Patient Recall Program. Inclusion criteria: dentate (ie, most natural teeth intact), most recent visit indicated early periodontitis/mildto-moderate gingivitis, age 30 to 75 years, medically healthy according to chart review and standard College of Dentistry medical questionnaire, anticipated ability to attend all 4 scheduled visits. Exclusion criteria: a significant medical condition (including but not limited to diabetes mellitus, rheumatic heart disease or clinically significant heart murmor).

Sample size estimate With 2-tailed α = 0.05, the estimated sample size required for 1-β = 0.8 to detect a clinically important treatment effect on each surrogate outcome was 60 paired observations.

Inclusion criteria:

Nine additional participants were randomized to anticipate attrition.

Of the 78 volunteers, there were 7 screen failures: 1 failed to attend 2 first appointments, 3 diabetics, 3 could not commit to the followup appointment schedule. Two replacements were recruited when the first 2 dropouts failed to return after only their initial baseline data had been collected, ie, systematically assigned, and therefore a protocol violation. It was agreed not to dismiss the replacements and treat both as though they had been randomized.

Among 71 participants, 5 dropped out: 1 cited conflict with work commitments, 2 missed one or more follow-up appointments because they went on vacation during the study, 1 moved out of the country, 1 had orthodontic appliances placed after entering but before completing the study; 66 completed the entire protocol.

Study design This was a randomized, shamcontrolled, double-blind, crossover with a 14-day washout between 2 14day treatment periods, and included a small parallel control arm (Figure 2).

The treatment arm allocation scheme was generated to randomly assign 69 participants to one of 3 treatment arms: A = 37, B = 26, C = 6 (GraphPad Software Inc, San Diego, CA. http:// www.graphpad.com/quickcalcs/ randomize1.cfm). Concealment was maintained by coding the active and control toothbrushes with 4 different color tags, which resulted in multiple color pairs for each arm of the study. The code was kept sealed

dentate (ie, most natural teeth intact), most recent visit indicated early periodontitis/ mild-to-moderate gingivitis, age 30 to 75 years, medically healthy…

by the statistician until the study was completed. The outcome variables were: Gingival Index (Löe & Silness method), Periodontal Index (Ramfjord method, Michigan “0” probe with Williams markings, assess pocket depth and bleeding), gingival crevice fluid flow (Löe & Holm-Pederson method, measured by Periotron® densitometer, model 304/6000, Harco Electronics, Winnipeg, MB, and Periopaper® gingival fluid collection strips, Pro Flow Inc, Amityville, NY; calibration and stability established using 1 μL from thawed aliquots of a single human serum sample, and 1 μL ultrapure water as an external reference), gingival crevice temperature (Thermalert TH-5, Bailey Instruments, Lancashire, UK), and Plaque Index (Quigley & Hein method). Although the menstrual cycle has been shown to influence gingival crevice fluid flow (8), most women approximate a 28-day cycle.

A 14-day treatment period followed by a 14-day washout period ensures that cycling women will be fairly close to the same stage of their menstrual

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cycle at the beginning of both treatment periods. Two registered dental hygienists worked together to collect all of the data. Each of the outcome variables were measured on both the labial and buccal surfaces of 6 representative teeth: the 1.6, 2.1, 2.6, 3.6, 3.1, and 4.6.

Analytical design Mann-Whitney 2-sample t tests for period differences on main effects were undertaken to detect carryover effects. Two-way ANOVA was used to screen for treatment × period interactions for each outcome variable. Differences between the first and second baseline measurements were also examined for evidence of an inadequate washout, and between

arms at the first baseline (unequal correlations or unequal variances) to assess the relative effectiveness of randomization to treatment. Oneway repeated measures ANOVA with Bonferroni multiple comparisons post test for selected pairs if p < 0.05 was used to assess treatment differences in interval data: pocket depth, gingival crevice fluid flow, and gingival crevice temperature. Friedman nonparametric repeated measures ANOVA with Dunn’s multiple comparisons test was used to assess treatment differences in ordinal data: Gingival Index, bleeding, and Plaque Index. The outcome variables were reanalyzed as though they were all continuous interval data for the purpose of retrospectively estimating

the power (1 – β) of the completed study to detect minimum clinically important differences.

Results The sample baseline characteristics are tabulated (Table 1). There were no significant between group differences at baseline.

The parallel control × control arm generated 6 paired observations. The 2 baselines did not differ. There were no period differences comparing means of absolute values or as changes from baseline. The arm was powered to detect a change in crevice fluid flow (mean difference

Table 1. Sample Baseline Characteristics ([SD) [95% CI]).

CHARACTERISTIC

Active-to-Inactive Arm (n = 37)

Inactive-to-Active Arm (n = 26)

Parallel Control Arm (n = 6)

Gender (percent male:female)

35.7

38.9

50.0

Age (years)

51.2 (11.2) [47.5, 54.9]

48.5 (10.1) [44.4, 52.5]

45.5 (9.3) [35.7, 55.3]

Gingival Index

0.21 (0.21) [0.15, 0.29]

0.38 (0.36) [0.25, 0.51]

0.27 (0.30) [-0.05, 0.59]

Periodontal Index (pocket) (bleeding)

1.86 (0.31) [1.75, 1.96] 0.0 (0.0) [na]

1.86 (0.43) [1.70, 2.02] 0.0 (0.0) [na]

1.80 (0.32) [1.50, 2.10] 0.0 (0.0) [na]

Gingival Crevice Fl. Flow

21.94 (27.86) [12.51, 31.37]

35.41 (29.94) [24.43, 46.39]

41.96 (23.94) [18.43, 67.39]

Gingival Crevice Temp.

33.98 (0.59) [33.78, 34.18]

33.97 (0.77) [33.69, 34.25]

33.02 (1.17) [31.39, 34.95]

Plaque Index

1.11 (0.48) [0.95, 1.28]

1.26 (0.49) [1.08, 1.44]

1.32 (0.54) [0.74, 1.90]

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Table 2. Comparison of 67 paired pre- and post- crossover baselines.

OUTCOME

MEAN DIFFERENCE

95% CI

P VALUE

Gingival Index

-0.03

-4.3, 4.4

NS

Periodontal Index

-0.07

-4.3, 4.4

NS

Crevice Fl. Flow

24.76

16.7, 32.8

<0.001

Crevice Temp.

-0.41

-3.9, 4.7

NS

Plaque Index

-0.04

-4.3, 4.4

NS

Table 3. Comparison of Active vs Control Toothbrushes, changes from baselines.

OUTCOME

MEAN DIFFERENCE

95% CI

P VALUE

Gingival Index

0.1083

-7.394, 7.611

NS

Periodontal Index

0.4370

-7.066, 7.940

NS

Crevice Fl. Flow

18.732

7.976, 29.489

0.0009

Crevice Temp.

-0.9382

-8.441, 6.565

NS

Plaque Index

-0.3704

-7.873, 7.132

NS

4 Periotron Units (PU) [95%CI: -7.4, 15.4]) or crevice temperature (mean difference 0.79º (95%CI: -10.6, 12.2]).

The second period baseline mean crevice fluid flow was markedly higher than the first period baseline mean; difference = 25 PU [95%CI: 16.67, 32.83]), p <0.001. The power to detect a minimum clinically important difference of 7 PU was about 0.99.

The baselines were otherwise virtually identical (Table 2). Within-period changes were calculated for each subject from that subject’s own baseline measurement (paired data), before comparing the change in crevice fluid flow between the active and control arms. The change in crevice fluid flow following use of the active brush was 29.352 ± 42.37 PU, and 10.620 ± 35.091 PU following use

of the control brush (mean difference = 18.732, [95%CIdiff.: 7.976, 29.489], p=0.0009).

There was no significant difference in the change from baseline of crevice temperature. Dunn’s Multiple Comparisons following Friedman nonparametric repeated measures ANOVA showed no significant differences in rank sum

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means between active and control toothbrushes for Gingival Index, Periodontal Index or Plaque Index (Table 3). No gingival pocket bleeding was elicited during probing in any of the patients at any of the 4 visits.

Discussion A previous study that compared the active Soladey brush against a control brush with a similar number of patients and a less powerful design reported a detectable trend in reduction in papillary-marginalattached index (PMA-I) for gingivitis within the first 1-to-2 weeks that reached stochastic significance by 3 weeks (6). Other studies comparing the active Soladey brush against a control brush have reported reductions in plaque scores as early as one week, even in a small sample (5, 7). The current study was designed to minimize bias in clinical indices of gingivitis and periodontitis and was powered to detect changes in multiple sensitive measures of periodontal inflammation. Gingival crevicular fluid flow and subgingival temperature are effective measures of periodontal inflammation (9, 10, 11).

In a randomized cross-over study with two 28-day periods separated by a 14day washout, Moreira and colleagues compared the effects on gingival crevicular fluid of an ionic toothbrush from another manufacturer (HyG ionic, Hukuba Dental Corp, Japan), and concluded that the ionic brush performed no different than a conventional toothbrush (12).

Perhaps other modalities such as optical spectroscopy would provide

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sensitivity to detect more subtle early evidence of efficacy (13).

Conclusion According to multiple clinical parameters and sensitive response variables selected for this study, the Soladey-3 TiO2 semiconductorcontaining toothbrush did not confer any advantage over a conventional toothbrush in adult patients with mild-to-moderate gingivitis/ periodontitis.

ACKNOWLEDGMENTS: Research Services, University of Saskatchewan. Administrative processing of application for investigational testing authorization, ethical review and ongoing monitoring of research involving human subjects.

College of Dentistry, University of Saskatchewan. Clinical research space and administrative support.

Dr James Stakiw (retired), former acting dean, College of Dentistry, University of Saskatchewan, and executive PI during the trial. Dr Stakiw made a very substantial intellectual contribution as clinical expert periodontist.

Dr Kunio Komiyama, professor emeritus, College of Dentistry, University of Saskatchewan. He secured the funding and toothbrushes for this study from Shiken Corp; he negotiated clinical research space, and hired the dental hygienists.

Texas Dental Journal l www.tda.org l February 2015

Dr Yoshinori Nakagawa, president and CEO, SHIKEN Co, Ltd, Osaka, Japan.

He graciously provided unrestricted funding and supply of active and inert toothbrushes for this study.

REFERENCES 1. Kleinberg I. Regulation of the acid-base metabolism of the dento-gingival plaque and its relation to dental caries and periodontal disease. Journal of the Canadian Dental Association 1974;40:56-66 2. Oliver C, Holm-Pederson P, et al.

The correlation between clinical scoring, exudates measurements and microscopic evaluation of inflammation in the gingiva.

Journal of Periodontology 1969;40:13-21.

3. Matsunaga, T. Sterilization with particulate photosemiconductor.

Journal of Antibacterial and Antifungal Agents 1985;13:211220.

4. Morioka T, Saito T, Nara K, Onoda K. Antibacterial action of powdered semiconductor on a serotype g Streptococcus mutans.

Caries Research 1988;22:230-231.

5. Hoover JN, Singer DL, Pahwa P, Komiyama K. Clinical evaluation of a light energy conversion toothbrush. Journal of Clinical Periodontology 1992;19:434-436.

6. Niwa M, Fukuda M. Clinical study on the control of dental plaque using a photo energy conversion toothbrush with a TiO2 semiconductor. Shigaku 1989;77(2):598-606.

7.

8.

9.

Kusunoki K, Oku T, Kon’i H, Nakaya K, Mori T, Hiratsuka Y, et al. A study on the effect of the solar energy toothbrush on the control of dental plaque. Shika Igaku 1986;49(4):550-559.

Markou E, Eleana B, Lazaros T, Antonios K. The influence of sex hormones on gingiva of women.

The Open Dentistry J 2009;3:1149.

Griffiths GS. Formation, collection and significance of gingival crevice fluid. Periodontol 2000 2003;31:32-42.

10. Wolff LF, Koller NJ, Smith QT, Mathur A, Aeppli D. Subgingival temperature: relation to gingival crevicular fluid enzymes, cytokines, and subgingival plaque micro-organisms. J Clin Periodontol 1997;24:900-6.

11. Niederman R, Naleway C, Lu BY, Buyle-Bodin Y, Robinson P. Subgingival temperature as a gingival inflammatory indicator. J Clin Periodontol 1995;2:804-9.

12. Moreira CHC, Luz PB, Villarinho EA, Petri LC, Rösing CK. Effficacy of an ionic toothbrush on gingival crevivular fluid – a pilot study. Acta Odontol Latinoam 2008;21:17-20.

13. Liu KZ, Xiang XM, Man A, Sowa MG, Cholakis A, Ghiabi E, et al. In vivo determination of multiple indices of periodontal inflammation by optical spectroscopy. J Periodontal Research 2009;44:117-24.

PLACE YOUR NEXT DISPLAY AD HERE! Display advertising in the Texas Dental Journal is one of the best ways to reach the majority of Texas dentists. The Texas Dental Journal is the official publication of the Association. Established in 1883, it is the longest, continuously published dental journal in the Americas and second in the world to the British Dental Journal. Published monthly, the Journal’s circulation exceeds 9,000, its readership exceeds 50,000, and it’s the only statewide publication of its kind to reach the majority of Texas dentists. TDA Perks Partners, allied groups, and non profits receive discounts!

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Dental Artifacts The Trusting Face of Early Twentieth Century Dentistry Kim Freeman, MA, DMD, MS

I

magine yourself in a baseball stadium in July 1915. It is so hot that you dared to loosen your tie and accept a free fan to stir the sultry humid air. You look at the fan and it is the face of “America’s Greatest Dentist.”

Dentist”. As you use the fan you fan, youan cansee seeDrDrHyman’s Hyman’seyes eyes following you.

Your curiosity gets the better of you and you flip the fan over to see who this is.

It is dental Shangri-La. Shangrila. Cheap, Cheap,painless, painless,and andaanumber numberofof locations so that one must MUSTbe beclose closeby. by.Free Freeadvice adviceand and suction dentures are an obvious match made in heaven!

Heaven!

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Texas Dental Journal l www.tda.org l February 2015

The prices on the other dentistry are great, great one you thinks. think.

I have You have been been having having trouble trouble with with a tooth a tooth in the in the back back, so I decide so you decide to go. to go.

Being go there. to thatI sit office.

You Being close close to to Germantown, Germantown, you I went down insit the down in the chair and wait for Dr Hyman.

You are told he chair and wait for Dr Hyman. I was told he never comes never comes to work anymore since he locations. has all these to work anymore since he has all these I asked locations.

You ask the barely-past-puberty dentist he the barely-past-puberty dentist if he thought it wasif right thought was right that you supposed to see Dr that I wasit supposed to see Drwere Hyman “America’s Greatest Hyman, “America’s Greatest Dentist,” and were instead Dentist” and was seeing an inexperienced dentist? seeing an inexperienced dentist?

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PREVIEW Treating Patients with Anxiety or Special Needs: There’s Always a Way Harvey Levy, DMD, MAGD

I

magine you are driving to work and encounter a roadblock. You detour and make it to your destination, albeit late. Management of anxious patients similarly starts out on a main road. Due to circumstances beyond your control, you are forced to try another approach or 2, or even 3. Eventually, you arrive, having treated your patient successfully.

Anxious Patients Anxiety by definition is “worry gone out of control” (Figure 1). It is irrational but frighteningly real to the patient. Unless you’ve experienced anxiety, you cannot understand it. Try describing the color blue to a congenitally blind person and you will appreciate the impossibility of understanding a patient’s situational anxiety.

Now magnify that anxiety with the kind of fear felt by children too young to understand, Alzheimer’s patients who can no longer understand, mentally challenged patients who never understood, or autistic patients who live within an isolated world. Not all anxious people are special-needs patients, but all patients with special needs are anxious.

How do we gain the cooperation of anxious patients so we can treat them? There is always a way. Always!

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Texas Dental Journal l www.tda.org l February 2015

Figure 1. Anxiety is worry gone out of control.

Prescription Drugs for Conscious Sedation, Plus Nitrous Oxide We start by relaxing the patient with some medicine. We prescribe an oral sedative the night before and/or just before the appointment. Nitrous oxide gas may be given as a supplement.

Our office protocol has been successful in 96% of our 35,000 oral sedation cases.

Patients are relaxed enough Figure 2. Anxious patient relaxing comfortably with nitrous oxide. to be wrapped, propped, radiographed, and treated to completion.

Wraps To prevent patients’ selfinjurious behavior, we restrain their hands using soft wraps (Figure 3).

We place the wrap onto the operatory chair before the patient is seated (Figure 4).

We then seat the patient and gently secure the wrists Figure 3. Anxious boy is comfortable and safely with Velcro (Figure 5) and restrained with wrap. the legs (Figure 6) to prevent sudden movement.

The head is immobilized by commercial head restraints or by a caregiver.

Dr Harvey Levy’s Class Schedule at the TEXAS Meeting:

Harvey Levy, DMD, MAGD

FRIDAY, MAY 8TH Successful Office Management of Anxious and Special-Needs Patients 8:00 AM – 11:00 AM Course Code F48 Portable Dentistry: Successful OR and Off-Site Management of Patients 1:00 PM – 4:00 PM Course Code F49 SATURDAY, MAY 9TH Tips, Tricks, Techniques and Tools for Managing Anxious Patients 8:30 AM – 11:30 AM Course Code S20

Figures 4-6. Applying the wrap in 3 easy steps.

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Mouth Props To open the mouth, we start with a foam-covered mouth rest (Figures 7,8).

Figure 7. Open Wide™ mouth rest is inserted horizontally.

Figure 8. Open Wide™ mouth rest is rotated vertically.

We then switch to a ratchet mouth prop (Figure 9).

Figure 9. Molt ratchet prop is inserted for wider opening.

What if the patient will not open?

There’s always a way. A simple technique prompts the patient to open the mouth, with a >98% success rate. We pinch the nose while hovering around the lips with the mouth rest. As soon as the patient takes a breath, we slide in the mouth rest and rotate as illustrated (Figures 10,11). The remaining 2% are opened by techniques taught in our hands-on courses.

Figures 10 and 11. Pinching the nose forces patient to open mouth.

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Texas Dental Journal l www.tda.org l February 2015

Once the mouth prop is in the vertical position, you can easily insert and immobilize a ratchet prop (Figure 14).

We often use a combination mouth prop, tongue retractor, cheek retractor, saliva ejector, and light source to illuminate the mouth (Figures 15,16).

Figure 14. Finger on hinge of ratchet prop.

Figure 15. Isolite™ retractor inserted into mouth.

Figure 16. Isolite™ with light illuminates the mouth.

Accessibility According to the Americans with Disabilities Act, an office must accommodate wheelchairs. We use movable operatory chairs, displayed below (Figures 17,18).

Figures 17 and 18. DentalEZ Airglide™ chair can be pushed aside to allow patient to remain in own wheelchair.

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A switch turns the heavy operatory chair into a hovercraft. A cushion of forced air allows a clinician to move the chair out of the way with one finger. This enables patients to remain in the comfort of their wheelchair or gurney (Figure 19).

Figure 19. Patient being treated in own gurney.

When wheelchairs don’t have a headrest we clip one on, or use the chest of a caregiver as shown in Figure 20.

Figure 20. Our favorite headrest is a caregiver’s chest.

Radiographs For radiographs we love the portable, hand-held, cordless x-ray units (Figures 21,22).

Figures 21 and 22. Nomad™ and Nomad Pro™ hand-held X-ray units.

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Digital imaging X-ray systems enable us to expose, process and immediately view images, and retake within seconds (Figures 23,24).

What if you don’t have an assistant, a functioning computer, or electric power? Our answer is self-developing dental film in conjunction with a hand-held X-ray unit (Figures 25,26).

For about $1, you have a complete film and darkroom enclosed within a packet the size of a #2 dental film.

Figures 23 and 24. Nomad™ and DEXIS™ being used in the operating room.

A high quality film results when the film packet is exposed, withdrawn, squeezed, and rinsed with water.

Moderate sedation Relaxing the patient more deeply requires moderate sedation. The dentist must hold a Class I permit, which generally requires a 3-day course, ACLS card, and site visit.

Figure 25. Ergonom-X™ selfdeveloping film.

Figure 26. Nomad-Pro™ and Ergonom-X™ self-developing film being used together.

Operating Room: A Path that Always Works When all else fails, I work on the ideal patient: one who is asleep and cannot spit, bite, kick, hit, or resist treatment in any way. When a patient is under general anesthesia, it is guaranteed that you will complete the case.

Success depends only on your clinical dental skills, where you can do your finest dentistry (Figure 27).

We have calculated, based upon our latest 1,500 O.R. cases, that the hourly net income in the O.R. is more than 4 times that of our office cases.

All our O.R. work is done with no interruptions by the patient (Figure 28).

Advantages to having work done in the O.R. include: 1) This may be the patient’s last resort; 2) The patient

Figure 27. A dentist’s ideal clinical setting. Figure 28. The author with a hygienist and 2 dental assistants treat a patient in the operating room.

has no memory of being restrained or operated on; 3) The work gets done 4 times faster than it would in an office.

To treat patients in an O.R., you do not need a special permit. You only need what you already have: a license, insurance, and basic CPR card.

Conclusion Every patient can be treated successfully, in a dental office or in

an operating room. Determining the best path for each patient requires resourceful creativity that results from knowledge, skill, and practice. If you have the motivation, you can learn the clinical skills in CE courses. There’s always a road that will enable you to treat any patient.

For copies or comments, please contact Dr Harvey Levy at DrHLevy@ gmail.com or visit DrHLevyAssoc.com.

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LAW OFFICES OF HANNA & ANDERTON EXPERIENCED LAWYERS REPRESENTING TEXAS DENTISTS MARK J. HANNA, JD Former General Counsel, Texas Dental Association

* Representation Before the Texas State Board of Dental

Examiners

* Medicaid Audits and Administrative Hearings * Employment Issues - Texas Workforce Commission

Hearings

FRANK B. WALKER, JD Former General Counsel, Texas State Board of Dental Examiners

* Standard of Care Reviews and Expert Opinions * Employment/Associateship Contract Reviews * Practice Acquisition and Sales * Business Organizations, PAs, PCs, and LLCs

ROBERT M. ANDERTON, DDS, JD, LLM Past President, Texas Dental Association and American Dental Association

* Risk Management Consultation and Compliance

Reviews

* Civil Litigation

900 Congress Avenue, Suite 250 Austin, Texas 78701 Phone: 512.477.6200 Fax: 512.477.1188 Not Board Certified by the Texas Board of Legal Specialization

1066Texas Texas Dental Journall 130 Dental Journal

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Provided by TDA Perks Program

value for your

profession

By Eric Tiedtke, CFP, TDA Financial Services Insurance Program

T A

Filling Gaps in the Affordable Care Act’s Coverage Using Health Savings Accounts and Supplemental Coverage 132

Texas Dental Journal l www.tda.org l February 2015

he nyone Affordable that had Care to Act get(ACA) individual provides health comprehensive insurance or is coverage in the and process has of many getting goodcoverage features:via guaranteed the federal marketplace issue—no prehas existing-condition figured out that “affordable” limitation or riders, and “reasonable” and no lifetime apparently benefit limits have different (based on meanings dollar amounts); in first-dollar Washington, preventive D.C., thancare theyfor essential do in Texas. benefits The reality including is that physicals, premiumswell are higher, womanasexams, are well deductibles child care, andpediatric out-of-pocket dental, maximums. and immunizations—all Unless you receive without a subsidyanoroffice-visit premium tax copay credit or deductible based on your if done income in-network; and family no restricted size, your health annualinsurance limits (on the dollar premium value); is probably and full higher maternity than coverage what you and weredependent paying before the coverage AffordableupCare to age Act26.

(ACA).

However, these mandated benefits add costs, The ACA andprovides not everyone comprehensive wants or needs coverage them. andFor hasexample, many good very few features: dentists guaranteed want to purchase issue—no dental pre-existing-condition insurance for their limitation children. or riders, and no lifetime benefit limits (based on dollar amounts); Insurance first-dollarcompanies preventive are care for essential benefits including now limited on how they can physicals, well woman exams, differentiate themselves because wellplan childdesigns care, pediatric the are dictated by dental, and immunizations—all ACA. The companies try to do this without office-visit copay or by havingandifferent deductibles for deductible their plans, if done additional in-network; or no different restricteddeductibles annual limits or(on copays the for dollar prescription value); and drugs full maternity or coverage and dependent specialist visits, or by limiting coverage up to ageThe 26. However, office-visit copays. reality is these mandated the plans are verybenefits similar add when

costs, you consider and notthe everyone actual out-of-pocket wants or exposure needs them. (theFor most example, you’ll pay verybefore few the plan want dentists pays 100%). to purchase dental insurance for their children.

The biggest difference among companiescompanies Insurance is their managed are nowcare networks. limited on You howneed they to canunderstand differentiate what PPO, EPO, themselves because and HMOs the plan are, designs as 2 of the dictated are 3 don’t have

by ACA. any The out-of-network companies coverage, try to do this except by having in emergencies. different You should also be deductibles foraware their plans, that companies additional often or different have more deductibles than one or network, copays for so simply calling prescription drugs your or specialist physician’s visits, office or by limiting and asking office-visit if it takes copays.

Blue The Cross, Aetna, reality is the plans or United are very Healthcare, similar for instance, when you consider isn’t enough. the actual It’s out-ofcritical you understand pocket exposureand (thecheck most each you’ll pay company’s before the plan managed pays 100%). network, and understand the terms above, before you get The biggest coverage. difference among companies is their managed care networks.

You need What can I do totounderstand keep my what PPO, EPO, and HMOs are, as 2 of premium down the 3 don’t have any?out-of-network coverage, except in emergencies. You Now that you’re completely confused should also be aware that companies and/orhave depressed, what arenetwork, some often more than one options to help with the overall so simply calling your physician’s cost? way reduce your office The and best asking if ittotakes Blue premium—other than limiting your Cross, Aetna or United Healthcare, network (in and with an or for instance, isn’tout) enough.

It’sHMO critical EPO—is having a higher deductible. you understand and check each If you wantmanaged the convenience ofand an company’s network, office-visit or prescription drug copay, understand the terms above, before consider a plan with the highest you get coverage. deductible you’re comfortable with. But before you enroll in this W hat can I do to keep my plan, compare it to an HSA High premIum doWnPlan ? (HDHP) Deductible Health offered by the same company or a Now that you’re confused competitor.

Lookcompletely at the difference in and/or depressed, whatthese are some the premium between plans: options help with the overall it can beto20-30% or more.

If the cost?

Theyou best way on to reduce yourbasis amount spend a monthly premium—other thanoffice limiting your for prescriptions and visits is network (in and HMO or substantially lessout) thanwith thisan difference, EPO—is a higher deductible. it makes having sense to consider the HDHP If youan want with HSA.the convenience of an

office-visit What isoranprescription HSA? drug copay, consider a plan with the highest deductible you’re What exactly is ancomfortable HSA? It’s a bank with. Butyou before in and this can account ownyou andenroll control plan, compare it to an HSA High make tax-deductible contributions to, Deductible PlanHDHP. (HDHP) if you have Health a qualified The HSA offered by the same company or a allows you to prefund future expenses competitor. theself-insurance difference in and build upLook youratown the premium between these plans: account. Dentists typically make it can be 20-30% or more.

If the too much money to deduct medical amount you a monthly basis expenses, sospend this is on a way to deduct for prescriptions and office visits is expenses that you’re currently paying substantially less than this difference, for with after-tax dollars. it makes sense to consider the HDHP with an HSA. For 2015, you can contribute a maximum of $3,350 for an individual plan and Is $6,650 for a family plan. A What an hsa? family plan is defined as having two or more insureds. not What exactly is an Contributions HSA? It’s a bank used in one year can be rolled over to account you own and control and can the following year—it’s not “use-it-ormake tax-deductible contributions to, lose-it” as it is in health care flexible if you have a qualified HDHP. The HSA spending Contribution allows youaccounts. to prefund future expenses amounts are scheduled to be indexed and build up your own self-insurance annually inflation.

Persons account. for Dentists typically make between ages 55 and 65 canmedical make too much money to deduct additional “catch up” contributions expenses, so this is a way to deduct of up to $1,000 a year.currently Contributions expenses that you’re paying can be made as late as April 15 of for with after-tax dollars. the following tax year. A $7,650 HSA For 2015, you can contribute a maximum of $3,350 for an individual

contribution in the tax bracket plan and $6,650 for28% a family plan. A is $2,142plan thatisUncle Samasdoesn’t family defined having get twoto spend. or more insureds. Contributions not used in one year can be rolled over to Want more information?

Go“use-it-orto: irs. the following year—it’s not gov/pub/irs-pdf/p969.pdf or flexible check lose-it” as it is in health care with your accounts.

CPA or taxContribution professional to spending be sure this the most for amounts aremakes scheduled to besense indexed your particular situation. annually for inflation. Persons between ages 55 and 65 can make W hat about thecontributions big additional “catch up” of up to $1,000 deductible ? a year. Contributions can be made as late as April 15 of the following tax the year.least A $7,650 HSA Okay, you picked expensive contribution in the 28% tax bracket HSA plan, set up an HSA and fundedis $2,142 that Uncleyou Samstill doesn’t it.

Unfortunately, have aget to spend. $12,000 (or higher) in-network outof-pocket maximum, double that Want more information? to: irs. for out-of-network, or no Go coverage gov/pub/irs-pdf/p969.pdf check out-of-network (other thanorfor with your CPA or tax professional emergencies) if you have an HMOto or be this makesthat’s the most sense for EPOsure plan.

Maybe not something your particular situation. you worry about, as you’re in good health and haven’t been a big user of health Do you likebIg to ski? Hike?

W hatcare. about the Travel? How about your spouse? Are deductIble? any of your children accident-prone or just What if aexpensive distracted Okay,plain youactive? picked the least texter runsset a light hits you?

Ever HSA plan, up anand HSA and funded been t-boned by an Escalade?

You it. Unfortunately, you still have a $12,000 (or higher) in-network outof-pocket maximum, double that

Texas Dental Journal l www.tda.org l February 2015

133

for out-of-network, can be out of pocketorthousands no coverage of dollars in a hurry(other out-of-network through thannofor fault of your own. If you emergencies) if you have have several an HMO yearsorof contributions EPO plan. Maybe in your that’s HSA, notyou something may feel worry you pretty about, comfortable. as you’re If not, in good there are some health andproducts haven’t and beenservices a big user youof might want health care. to Doconsider you like to to protect ski? Hike? yourselfHow Travel? in the about interim. your spouse? Are any of your children accident-prone or just plain active? What if a distracted S upplemental Insurance texter runs a light and hits you? Ever been t-boned by an Escalade? You Supplemental insurance plans can be out of pocket thousands of typically pay a cash benefit to the dollars in a hurry through no fault of insured. There is no coordination of your own. If you have several years of benefits with other health or disability contributions in your HSA, you may insurance. The money can be used to feel pretty comfortable. If not, there pay medical bills, cover a mortgage, are some products and services you or anything else you want. You’re in might want to consider to protect complete control of how the funds are yourself in the interim. used.

There s upplemental are different types Insurance of coverage

available, so you can select coverage that fits your situation Supplemental insurance best. plans Two of the mostpay typically common a cashand benefit popular to the are critical illness insured.

There(for is no a specific coordination disease) of and accident benefits with health other health insurance. or disability insurance.

The amoney can betoused They each pay set amount the to insured pay medical whenbills, a qualified cover a event mortgage, occurs. or anything Critical elseillness you want. insurance You’re in typically provides complete control of thehow full the policy funds are benefit in a lump sum payment upon used. diagnosis of a critical illness listed There are different coverage in the policy, such astypes heartofattack, available, so you can select disease, coverage stroke, cancer, Alzheimer’s that fitsneed yourfor situation best.

Two of or the an organ transplant.

Accident the most health common insurance and popular typically are reimburses critical illness you (for fora medical specific costs disease) resulting and accident fromhealth accidents. insurance.

These plans each They can include pay a set a hospital amount benefit to the that payswhen insured a setaamount qualifiedwhen event you’re admitted occurs.

Critical to a hospital. illness insurance Premiums are usually low and nofull medical typically provides the policyexam is required. are good options benefit in a These lump sum payment upon diagnosis of a critical illness listed

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forthe helping offset risk ofattack, having in policy, suchthe as heart a high deductible and out-of-pocket stroke, cancer, Alzheimer’s disease, maximum. or the need for an organ transplant.

Accident health insurance typically reimburses you for medical costs W hat about Travel? resulting from accidents. These plans can include a hospital benefit Even with the most comprehensive that pays a set amount when you’re health insurance, there are coverage admitted to a hospital. Premiums gaps. Most plans will cover you for are usually low and no medical exam emergencies when you’re traveling is required. These are good options overseas, however the related charges for helping offset the risk of having are almost always out of network. a high deductible and out-of-pocket Sometimes there’s no coverage at maximum. all. International medical coverage is an inexpensive option if you’ll be traveling W hat about outside the travel US. In?most cases, you purchase a set amount for the Even with period the most of time comprehensive that you’re traveling, health insurance, and the there policyare would coverage reimburse gaps.

Mostyour plansmedical will cover expenses you for up to the benefit emergencies when amount you’re iftraveling you’re outside the overseas, however US and the need related medical charges care. are almost always out of What if you’re injured or network. have a Sometimes no coverage at heart attackthere’s and need surgery when all.

International coverage traveling overseasmedical or in Alaska?

No is an inexpensive option you’ll health insurance pays to ifget you be and traveling outside US. What In most your spouse backthe home. if you cases, you purchase a set amount need lifesaving treatment and the for the period that you’re closest hospitalofortime surgeon is not up traveling, the policy wouldAir to the taskand (heard of Ebola?)? reimburse your medical ambulances costs tens ofexpenses thousands of dollars up to the benefit or more,amount and theif companies you’re expect payment outside the US and upfront. need medical If you care. travel,ifespecially What you’re injured out oforthe have country, a or volunteer heart attack and yourneed dental surgery services when in underserved traveling overseas areas,orlook in Alaska? at pre-paid No emergency health insurance assistance. pays to These get you plans and will coordinate and pay for yourif you your spouse back home.

What medical transportation—by plane, need lifesaving treatment and the helicopter, or ground ambulance—to closest hospital or surgeon is not up getthe youtask where youof can get proper to (heard Ebola?)?

Air treatment. costs tens of thousands ambulances of dollars or more, and the companies expect payment upfront. If you travel, especially out of the country,

Texas Dental Journal l www.tda.org l February 2015

Supplemental, travel, andand Supplemental, travel, pre-paid emergency assistance pre-paid emergency all can help offset the risk of assistance all can help unexpected medical related charges, offset the risk of unexpected and can eliminate or reduce the medical related charges, cost of a high deductible or and out-of-pocket can eliminate or reduce maximum. the cost of a high deductible or your dentalmaximum. services in orvolunteer out-of-pocket underserved areas, look at pre-paid emergency assistance. These plans will coordinate and pay for your Supplemental, travel, and pre-paid medical transportation—by plane, emergencyor assistance all can help helicopter ground ambulance—to offset risk of unexpected medical get youthe where you can get proper related charges, and can eliminate or treatment. reduce the cost of a high deductible or out-of-pocket maximum.

These Supplemental, travel, and pre-paid plans are inexpensive emergency assistance partly all canbecause help the likelihood of needing them is offset the risk unexpected medical relatively low.

Peace of mind is worth related charges, and can eliminate or something; and of youa high coulddeductible have these reduce the cost plans for many years withoutThese using or out-of-pocket maximum. them, need them once, and get all plans are inexpensive partly because your premiums back and more. the likelihood of needing them is relatively low. Peace of mind is worth If you’d like more information onthese something; and you could have any of these programs for you, plans for many years without using your or staff, please them,family, need them once, andcontact get all TDA Financial Insurance your premiumsServices back and more.

Program at 800-677-8644, or visit TDAmemberinsure.com.

If you’d like more information on any of these programs for you, For more information regarding this your family, or staff, please contact and other TDAServices Perks Program, please TDA Financial Insurance visit tdaperks.com, or call 512-443Program at 800-677-8644, or visit 3675.

TDAmemberinsure.com.

For more information regarding this and other TDA Perks Program, please visit tdaperks.com, or call 512-4433675.

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TDA MEMBER

SPOTLIGHT Is there something extraordinary about you that your peers might now know?

Do you have a hobby you would like to tell us about?

Are you working on a project that others might find interesting?

We Want To Hear From You! The TDA Today newsletter includes a feature article — “TDA Member Spotlight” — so you can learn more about your fellow dentists, their families, and their lives away from the office. If you would like to be included, or if you know of someone with an interesting story to tell, contact the publications team in the TDA Department of Member Services. Email Managing Editor Billy Callis at bcallis@tda.org or call 512-443-3675.

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MEMORIAL and HONORARIUM Donors to the Texas Dental Association Smiles Foundation

IN MEMORY OF: Robert Snell

Robertson Orchard Dental Associates

William Garnett

Robertson Orchard Dental Associates

Brian Certain

Dr Robert C Cody

Dr William Calhoun

17th District Dental Society

Dr Clifford Ochsenbein Dr L.K. Croft

Dr David McCarley

TAGD Staff, Board, and Members Dr Rise’ Martin Dr Matt and Nancy Roberts Michael Geeslin Judy and Becca Fairfield Dr David Ku Dr Jerry and Bettie Long Jackie and Gary Antweiler Dr Stephen and Allyson Wright Dr Yvonne Maldonado Datatax Linda and Steve Ortego Rex and Kay Eatmon Dr Jennifer Buchanan Capital Area Dental Society Dr John B Mason Amanda Riley Dr Jean Bainbridge Rebecca Smith The Board of Directors, Members, and Staff of the Texas Dental Association

In MEMORIAM Those in the dental community who have recently passed

David S. Hale Dallas, TX November 7, 1944 – December 26, 2014 Life Member: 2010 James W. Lewis Burleson, TX October 25, 1930 – January 12, 2015 Good Fellow: 1985 • Life Member: 1995 50 Year: 2010 Arthur C. Reed Jr Houston, TX July 24, 1930 – January 1, 2015 Good Fellow: 1982 • Life Member: 1995 50 Year: 2005 Reuben L. Willis Jr Cleburne, Texas August 4, 1925 – January 11, 2015 Good Fellow: 1974 • Life Member: 1990 50 Year: 2000

Your memorial contribution supports: • educating the public and profession about oral health; and • improving access to dental care for the people of Texas.

Please make your check payable to: TDA Smiles Foundation, 1946 S IH 35, Austin, TX 78704

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Oral and Maxillofacial Pathology Diagnosis and Management

Cherubism Oral and Maxillofacial Pathology Case of the Month (from page 100)

Differential Diagnosis Cherubism is a rare, non-neoplastic pathologic entity first described by Jones in 1933 in a family with several affected members. He designated the descriptive name “Cherubism” because “the full round cheeks and the upward cast of the eyes give the children a peculiarly-cherubic appearance (1, 2).” Cherubism affects mostly younger individuals and is usually inherited in an autosomal dominant pattern, although nonfamilial cases have also been reported (3). Cherubism presents as a painless jaw enlargement that typically affects both the maxilla and the mandible and is characterized by replacement of the osseous tissue by fibrous connective tissue.

Radiologically, the lesions appear as multiple, multilocular radiolucent spaces with distinct borders divided by bony septations, which often produces symmetric and dramatic jaw expansion. Cervical lymphadenopathy is not uncommon in those affected.

The disease is self-limiting and its natural history is to stabilize and remodel with time. Approximately 250 cases have been reported in published studies, mostly affecting males (4). In Cherubism normal bone is replaced by cellular fibrous tissue and immature bone. The mandible is the most severely

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affected bone. Bilateral swelling of the cheeks, and mandibular and maxillary enlargement causes orbital displacement and the tendency of ‘eyes looking up to the sky’ [3]. In most patients, Cherubism is due to dominant mutations in the SH3BP2 gene on chromosome 4p16.3.

Affected children appear normal at birth. Swelling of the jaws usually appears between 2 and 7 years of age, after which, lesions proliferate and increase in size until puberty.

The lesions subsequently begin to regress, fill with bone and remodel until age 30, when they are frequently not detectable. Fibro-osseous lesions in Cherubism have been classified as quiescent, non-aggressive and aggressive on the basis of clinical behavior and radiographic findings.

Quiescent cherubic lesions are usually seen in older patients and do not demonstrate progressive growth.

Non-aggressive lesions are most frequently present in teenagers.

Lesions in the aggressive form of Cherubism occur in young children and are large, rapidly growing and may cause tooth displacement, root resorption, thinning and perforation of cortical bone (5). Severity of the disease phenotype is highly variable, even within a family. Patients with a mild form of Cherubism may develop only small symmetric lesions in the mandible. The first radiographic signs of Cherubism are usually found in the

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region of the mandibular angle. These radiolucent lesions are asymptomatic but may affect development or eruption of permanent molars. The more progressive form of Cherubism manifests with multiple symmetrical lesions in the mandible or involves the mandible and maxilla with singular or multiple lesions. Although, Cherubism is usually limited to the mandible and the maxilla, there are rare reports of involvement of the zygomatic arches and condyles (6,7). Lesions in patients with the progressive form of Cherubism result in extensive bone resorption and leave only a fenestrated shell of cortical bone.

The clinical presentation of the case presented here was unusual in that the mandibular swelling was very slight and no other clinical signs or symptoms were present. Our clinical differential diagnosis included fibrous dysplasia, infantile cortical hyperostosis, hyperparathyroidism, central giant cell granuloma, and odontogenic cysts and tumors.

Hyperparathyroidism is rare in patients younger than 30 years unless the hyperparathyroidism is secondary to end stage renal disease, is not bilateral or symmetrical in presentation and shows elevated levels of serum calcium, serum alkaline phosphatase and decreased levels of phosphorus. Central giant cell granuloma is more common in the

anterior mandible, is rarely bilateral and frequently crosses the midline.

The histological features are similar to Cherubism, but present with a greater number of giant cells and increased background vascularity.

The radiographic presentation of our case was unique to Cherubism and allowed all the other entities listed in the differential diagnosis to be easily ruled out. Facial enlargement identical to Cherubism has been associated with various syndromes including Noonan Syndrome and neurofibromatosis Type I. Noonan syndrome was first described in 1963 and is characterized by short stature, hypertelorism, prominent posteriorly angulated ears, congenital heart defect, low normal intelligence or developmental delay, cryptorchidism in males, and bleeding disorders (8).

Dunlap et al. first reported on the Noonan syndrome and Cherubism association and presented 4 children at age 4 to 8 years old with the combination of the 2 entities (9).

Later, mutations of the PTPN11 gene and the SOS1 gene were identified in patients with Noonan syndrome (10-12). These findings support the notion that the giant cell lesions in patients with Noonan syndrome are distinct from Cherubism. There has also been a report of bilateral mandibular lesions in association with neurofibromatosis and a mutation in the NF1 gene, which is associated with neurofibromatosis and with Noonan Syndrome (13). Our patient did not have any of the stigmata associated with Noonan syndrome or neurofibromatosis. We have not performed genetic testing in the case presented here to confirm mutations in SH3BP2 gene or rule out Noonan syndrome and neurofibromatosis. The patient is being closely followed up for development of syndrome related signs and symptoms.

Because Cherubism is usually selflimiting, operative treatment is usually not be necessary. Longitudinal observation and follow-up is the initial management in most cases.

Surgical intervention with curettage, contouring or resection may be indicated for functional or aesthetic reasons. Surgical procedures are usually performed when the disease becomes quiescent. Aggressive lesions that cause severe functional problems such as airway obstruction justify early surgical intervention.

7.

8.

REFERENCES 1.

2.

3.

4.

5.

6.

Jones WA: Familial multilocular cystic disease of the jaws.

American Journal of Cancer 1933, 17:946–950.

Jones WA, Gerrie J, Pritchard J: Cherubism — familial fibrous dysplasia of the jaws. The Journal of bone and joint surgery British volume 1950, 32-B(3):334-347.

Mehrotra D, Kesarwani A, Nandlal: Cherubism: case report with review of literature. Journal of maxillofacial and oral surgery 2011, 10(1):64-70.

Tsodoulos S, Ilia A, Antoniades K, Angelopoulos C: Cherubism: a case report of a three-generation inheritance and literature review.

Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons 2014, 72(2):405 e401-409.

Papadaki ME, Lietman SA, Levine MA, Olsen BR, Kaban LB, Reichenberger EJ: Cherubism: best clinical practice. Orphanet journal of rare diseases 2012, 7 Suppl 1:S6.

Kalantar Motamedi MH: Treatment of cherubism with locally aggressive behavior presenting in adulthood: report of four cases and a proposed

9.

10.

11.

12.

13.

new grading system. Journal of oral and maxillofacial surgery: official journal of the American Association of Oral and Maxillofacial Surgeons 1998, 56(11):1336-1342.

Raposo-Amaral CE, de Campos Guidi M, Warren SM, Almeida AB, Amstalden EM, Tiziane V, RaposoAmaral CM: Two-stage surgical treatment of severe cherubism.

Annals of plastic surgery 2007, 58(6):645-651.

Noonan JA: Association of congenital heart disease with syndromes or other defects.

Pediatric clinics of North America 1978, 25(4):797-816.

Dunlap C, Neville B, Vickers RA, O’Neil D, Barker B: The Noonan syndrome/cherubism association.

Oral surgery, oral medicine, and oral pathology 1989, 67(6):698705.

Jafarov T, Ferimazova N, Reichenberger E: Noonan-like syndrome mutations in PTPN11 in patients diagnosed with cherubism. Clinical genetics 2005, 68(2):190-191.

Lee SM, Cooper JC: Noonan syndrome with giant cell lesions. International journal of paediatric dentistry / the British Paedodontic Society [and] the International Association of Dentistry for Children 2005, 15(2):140-145.

Tartaglia M, Zampino G, Gelb BD: Noonan syndrome: clinical aspects and molecular pathogenesis. Molecular syndromology 2010, 1(1):2-26. van Capelle CI, Hogeman PH, van der Sijs-Bos CJ, Heggelman BG, Idowu B, Slootweg PJ, Wittkampf AR, Flanagan AM: Neurofibromatosis presenting with a cherubism phenotype.

European journal of pediatrics 2007, 166(9):905-909.

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CALENDAR OF EVENTS APRIL2015 10-11 The TDA Smiles Foundation will hold a 40-chair, 2-day Texas Mission of Mercy in Dallas. For more information, please contact Missions Coordinator Sara Harney at TDASF, 1946 S IH 35 Ste 300, Austin, TX 78704; Phone: 512-448-2441; Email: sara@tda.org; website: tdasmiles.org.

17-18 The Arkansas Dental Association will host its Annual Scientific Session at the Statehouse Convention Center in Little Rock, AR. For more information please contact Ms Angela Rogers, ASDA, 7480 Highway 107, Sherwood, AR 72120; Phone: (501) 834-7650; Email: info@arkansasdentistry.org; Web: arkansasdentistry.org.

25-27 The Oklahoma Dental Association will host its Annual Meeting at the Tulsa Convention Center in Tulsa, OK. For more information please contact Ms Lynn Means, ODA, 317 NE 13th St, Oklahoma City, OK 73104; Phone: (405) 848-8873; Email: lmeans@okda.org; Web:okda.org.

MAY2015 7-10

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The Texas Dental Association will host its annual Texas Meeting at the Henry B. Gonzalez Convention Center in San Texas Dental Journal l www.tda.org l February 2015

Antonio, Texas. For more information, please contact Paula Tait-Lerash, annual session director, TDA, 1946 S IH 35 Ste 400, Austin, TX 78704; Phone: 512-4433675; FAX: 512-443-3031; Email: paula@ tda.org; Web: texasmeeting.com.

JUNE2015 12-13 The TDA Smiles Foundation will hold a 20-chair, 2-day Texas Mission of Mercy in Lufkin. For more information, please contact Missions Coordinator Sara Harney at TDASF, 1946 S IH 35 Ste 300, Austin, TX 78704; Phone: 512-448-2441; Email: sara@tda.org.

JULY2015 5-6

The Academy of General Dentistry will host its New Dentist Conference at the Omni Southpark in Austin, TX. For more information, please contact robin@tagd. org.

THE TEXAS DENTAL JOURNALâ&#x20AC;&#x2122;S CALENDAR will include only meetings, symposia, etc., of statewide, national, and international interest to Texas dentists. Because of space limitations, individual continuing education courses will not be listed. Readers are directed to the monthly advertisements of courses that appear elsewhere in the Journal.

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ADVERTISING BRIEFS PRACTICE OPPORTUNITIES ABILENE: 2- to 4-operatory stand-alone dental office with all equipment included; digital x-ray and pano.

Call 325-762-0444.

ABILENE: General practice for sale. Great area near the Air Force base; 3 colleges. Doctor retiring early due to difficulty with hands in need of surgery.

Full recall; several thousand records. Abilene is rated as one of the best family cities in the USA. Whether a buyer or a seller, trust your life’s work to the most experienced senior appraiser/broker.

For over 40 years, you have seen the name, Gary Clinton, appraiser, with the first 20 years as a dental consultant. Buyers, avoid over-payment for a practice and sellers, avoid selling below market value. Knowledgeable buyers are willing to pay the Fair Market Value in growth areas. My certified appraisals use market comparables from Texas practices located all over Texas. Senior Appraiser Member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially 1-800-583-7765.

ADS WATSON, BROWN & ASSOCIATES: Excellent practice acquisition and merger opportunities available. DALLAS AREA: 5 general dentistry practices

ADVERTISING BRIEF INFORMATION SUBMISSION AND CANCELLATION DEADLINE: 20th, 2 months prior to publication (eg, November 20th for January issue).

MONTHLY RATES: First 30 words = $60 for ADA members; $80 for non-ADA members; each additional word = $0.10.

Ads must be submitted via e-mail, fax, or web through tda.org and are not accepted by phone. Journal editors reserve the right to edit copy of classified advertisements. Advertisements must be not quote revenues or gross or net incomes; only generic language referencing income will be accepted.

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available (East Dallas, Richardson, Southeast of Dallas, and north of McKinney). FORT WORTH AREA: 2 general dentistry practices (West Fort Worth and Arlington). NORTH TEXAS: 2 pediatric practices.

HOUSTON AREA: 1 orthodontic practice. EAST TEXAS AREA: 1 general dentistry practice. WEST TEXAS AREA: 1 general dentistry practice. AUSTIN AREA: 1 general dentistry practice available northwest of Austin. BRYAN/COLLEGE STATION AREA: 1 general dentistry practice available. SAN ANTONIO AREA: 1 general dentistry practice available. OKLAHOMA AREA: 1 general dentistry practice available. For more information and current listings, please visit our website at www.adstexas.com or call ADS Watson, Brown & Associates at 469-222-3200.

ARGYLE: Dental practices for sale in Dallas, Richardson. Austin, Houston, San Antonio, Waco, Corpus Christi, College Station, East and West Texas.

For more information, call 888-429-5531 or visit ADSTexas.com.

ARGYLE: Nicely finished out, 2,000 sq ft out orthodontic office. Ideal satellite location for orthodontist, pedodontist, or oral surgeon. Russ Stover 817-706-5482, srstover@verizon.net.

ARLINGTON: General practice for sale in mid-town Arlington. Retiring dentist…grandchildren are calling.

Fast growing area. Outright sale. Transition at buyer’s request. Digital upgraded. Seven figure gross on 4 days; premier restorative family practice. Beautiful office with 5 operatories. Experienced dentist with specific skill levels. Two hygienists with profits that will cover the debt service. Whether a buyer or a seller, trust your life’s work to the most experienced senior appraiser/broker. For over 40 years, you have seen the name, Gary Clinton, appraiser, with the first 20 years as a dental consultant. Buyers, avoid

over-payment for a practice and sellers, avoid selling below market value. Knowledgeable buyers are willing to pay the Fair Market Value in growth areas.

My certified appraisals use market comparables from Texas practices located all over Texas. Senior Appraiser Member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially 1-800-583-7765.

AUSTIN (NORTH): Round Rock Dental Practice sale: Excellent visibility on Highway frontage, 6 plumbed operatories, and 3 currently furnished. The office has a beautiful modern décor, digital imaging and a tranquil feel. Clinic is less than 5 yrs. old, 20% growth rate with little marketing; 2014 net was

6-figures. Dentist is selling to concentrate on other non-dental businesses that are growing rapidly. austindentalopportunity@gmail.com.

AUSTIN NORTH CENTRAL: General practice. Well established on a major highway. Excellent signage.

2,200 sq ft, 4 operatories, easily expandable to 7. Free-standing building also available. Contact opportunity3077@gmail.com.

AUSTIN PRIVATE PRACTICE SEEKS ASSOCIATES (GPs, Prosthodontists) due to growth and increased capacity. Excellent compensation / benefits. Email resume to operations@omnidentalgroup.com or call 512-773-9239.

DDR Dental Trust

Serving Texas Dentists for more than 40 Years

• Practice Appraisals • Practice Sales • Associate Agreements

800-930-8017

James L. Dunn, Trustee Texas Dental Journal l www.tda.org l February 2015

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ADVERTISING BRIEFS AUSTIN, SAN ANTONIO & DALLAS AREA PRACTICE OPPORTUNITIES MCLERRAN & ASSOCIATES: CORPUS CHRISTI AREA (ID #T231): This is an opportunity to purchase an established, general dentistry practice located on the South Coast of Texas in an area that is experiencing rapid growth as a result of oil drilling in the nearby Eagle Ford Shale.

The practice has a large, fee-for-service/PPO patient base, strong new patient flow, consistent annual revenue in the mid-6 figures, and solid cash flow. The office occupies a free standing building with 2 fully equipped operatories (digital X-ray units and computers) and ample room to add 2-3 additional operatories. The real estate is owned by the seller and being offered for sale at fair market value. Given its close proximity to the Gulf of Mexico, this turnkey practice is an ideal opportunity for an avid fisherman/outdoorsman or beach lover. SOUTH OF SAN ANTONIO (ID #T235): This established general dentistry practice is located on a main thoroughfare in a quaint, rural town located approximately 90 miles southeast of San Antonio. This practice is in a high growth, low competition area in the Eagle Ford Formation. The practice has realized consistent annual revenue of 6 figures the past 2 years while maintaining low overhead, strong profitability of 50%, and solid new patient flow (currently averaging 27 new patients per month). The office space of the practice encompasses 1,200 sq ft and has 3 fully equipped operatories with digital X-ray units and computers (1 additional plumbed operatory for expansion). The building is also being offered for sale.

SAN ANTONIO (ID #T255): This established, general dentistry practice has a fantastic location on a busy street in a rapidly growing area of North San Antonio.

The practice boasts a large, predominantly fee-forservice patient base, consistent annual revenue of mid-high 6 figures, and exceptional net cash flow.

The office space has an attractive build-out, 4 fully

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equipped operatories with computers, and digital radiography. The practice has strong upside potential through increasing internal/external marketing and retaining services that are currently being referred to specialists. This opportunity will not last long! SAN ANTONIO (ID #T251): This established family practice is located in a free standing building on a busy street in a desirable neighborhood of San Antonio. The office space boasts an attractive/modern build out with 5 fully equipped operatories with digital X-ray units (ScanX) and computers. The practice has a predominately fee-for-service patient base. The seller is available to continue working in the practice on a part-time basis following the sale to facilitate a smooth transition of ownership. SAN ANTONIO (ID #T244): This established, general family practice is located in a newly built-out facility located in a vibrant, high traffic retail location in a desirable area of San Antonio. The practice caters to a middle to upper middle income, fee-for-service/PPO patient base and boasts a strong new monthly patient count as a result of strong patient referrals, online marketing, and a highly visible location. This truly is a one of a kind location in a great area of San Antonio.

SAN ANTONIO (ID #T239): A thriving multi-office pediatrics practice in the Seguin/San Marcos area is seeking a full time associate to work between both locations. Both facilities are state-of-the-art, featuring 12 treatment areas and the latest amenities, including a movie theater, arcade, ceiling mounted televisions, and toddler play areas. Both offices are designed for high volume patient flow, as they see an average of over 100 patients each day.

The patient base reflects the local blue-collar and educational communities. There is a mix of insurance, self-pay and state funded patients. The offices provide a full range of pediatric dental services and have very active sedation general anesthesia schedules. The associate doctor must be

ADVERTISING BRIEFS a graduate of a US dental school and hold a US pediatric dental training certificate. Spanish speaking is highly desired but not required. To learn more about this associate opportunity, please contact us at 512-900-7989 or texas@dental-sales.com. Please also send a current CV. EAST OF SAN ANTONIO (ID #248): This practice is located in a small professional building in a beautiful hill country town about 100 miles west of San Antonio. The practice currently operates as a part-time, low volume, low overhead operation and would be ideal for a dentist looking to practice part-time, acquire a satellite location, or acquire a practice in a low competition area. There is significant upside potential due to limited external marketing and limited involvement in discounted insurance plans. This is a great opportunity to get into an established practice for less than a comparable start up in a beautiful hill country community. The selling doctor is relocating for a new job out of private practice. HILL COUNTRY NORTH OF SAN ANTONIO (ID #T243): Doctor is retiring and selling this established quality general family practice and the building/real estate that is located in desirable hill country community within close proximity to San Antonio. The practice has seen consistent collections of approximately mid-6 figures per year over the past three years with strong cash flow. The practice caters to a fee-for-service/PPO, middle class patient base and boasts strong new monthly patient flow with limited external marketing.

The real estate will be sold at Fair Market Value as determined by an independent appraiser. WEST OF SAN ANTONIO (ID #T242): This established, fee-forservice general family practice was started from scratch in 1970 and has been in its current location for 28 years. The practice boasts a large active patient base, strong hygiene recall program, and excellent net cash flow after expenses. There is tremendous upside potential due to limited external

Top Associateships WE HAVE ASSOCIATESHIPS FOR EVERYONE > High revenue, high income practices > Solo private practices > Small/Medium Texas and regional groups > Public Health > Medicaid and kids practices > Correctional care positions with good salary + benefits > Native American Health Center positions For the past 12 years, AJ Riggins has been placing dentists in permanent jobs with dental practices and organizations in all parts of Texas.

Based in Dallas, we have our finger on the pulse of the Texas market.

AJ Riggins Health Search www.ajriggins.com 1-972-943-5773

marketing, no involvement in discounted insurance plans, a good amount of specialty work being referred out, and huge growth related to the Eagle Ford shale oil boom. This practice presents an excellent opportunity for someone who wants to get away from the San Antonio city life, while still having access to its amenities. NORTHWEST AUSTIN (ID #249): This state of the art perio practice features a beautiful, turn-key facility with modern decor, high end finish out, and 4 fully equipped operatories (with computers and digital X-ray units). The practice serves a PPO/Fee-for-service patient base, is currently seeing an average of 40 new patients per month, and is on pace to realize annual revenue of high-6 figures in 2014. You can purchase this turn-key practice for less than it would cost to start a practice

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ADVERTISING BRIEFS from scratch! AUSTIN (ID #T258): This is a rare opportunity to purchase an established orthodontic practice has an excellent location in a free-standing building situated directly on a busy thoroughfare.

The office space encompasses 2,400 sq ft and has 6 treatment chairs. The seller is available for a transition. You can purchase this practice for less than it would cost to start a practice from scratch!

AUSTIN (ID # T222): This is a unique opportunity to purchase a practice located in a busy retail center in Austin. The practice is ideal for a doctor or company looking for a large facility to establish a multiple doctor and hygienist office for less than the cost of building out a shell space and equipping a startup.

The practice has a total of 18 plumbed operatories with 6 operatories currently equipped. The practice revenue was on pace to be around the mid-6 figures in 2013 with only 1 doctor producing. Serious inquiries only as this is a unique opportunity not suited for most solo practitioners looking to acquire a practice. HILL COUNTRY WEST OF AUSTIN (ID #T236): This predominately fee-for-service general family practice is located in a desirable community in the heart of the Texas Hill Country. It boasts a great reputation and has been in its current location since 1980. The office has three fully equipped operatories, with the ability to add an additional operatory. There is a strong opportunity for growth, as the owner is not actively marketing the practice, does not participate in any PPOs and is referring out a fair amount of specialty procedures. The practice has a strong foundation of active patients with a good amount of upside potential. This is an excellent opportunity for someone who enjoys the beautiful Hill County and wants to get away from the big city.

Contact McLerran & Associates: David McLerran or Brannon Moncrief in Austin 512-900-7989, or San Antonio 210-737-0100. Practice sales, appraisals,

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buyer representation, and lease negotiations. To request more information on our listings, register at www.dental-sales.com.

AUSTIN: A well-established pediatric practice is seeking an energetic dedicated full-time pediatric dentist. We have an extensive client base with continued growth. Our office is a leader in all aspects of pediatric dentistry including sedation and anesthesia dentistry. We have 3 offices with stateof-the art technology and a highly trained support staff. We are looking for the right fit for our practice.

Ideally, someone who is looking for a long-term opportunity. New grads are welcome to apply. Please email resume to tal@austinchildrensdentistry.com.

AUSTIN: My Kidâ&#x20AC;&#x2122;s Dentist has an excellent opportunity for a pediatric dentist to work 10 days a month in our Austin offices. Contact Ed at 949-8427936 or email CV to looname@pacden.com for more information.

AUSTIN: Ortho practice for sale. The Texas economy especially in these areas is breaking records!

Control your destiny. Time to own your practice.

100% funding available at great rates. Practice is in a major shopping center. High traffic area.

Whether a buyer or a seller, trust your lifeâ&#x20AC;&#x2122;s work to the most experienced senior appraiser/broker.

For over 40 years, you have seen the name, Gary Clinton, appraiser, with the first 20 years as a dental consultant. Buyers, avoid over-payment for a practice and sellers, avoid selling below market value.

Knowledgeable buyers are willing to pay the Fair Market Value in growth areas. My certified appraisals use market comparables from Texas practices located all over Texas. Senior Appraiser Member of The Institute of Business Appraisers, Inc. Call Gary Clinton confidentially 1-800-583-7765.

ADVERTISING BRIEFS AUSTIN: AUSTIN: Part-time Part-time position position for for an an orthodontist. orthodontist.

Please Please submit submit your your resume resume to to jobs@ jobs@ capitalchildrensdentistry.com. capitalchildrensdentistry.com.

BRYAN/COLLEGE BRYAN/COLLEGE STATION: STATION: Relationship Relationship based based practice practice in in Bryan/College Bryan/College Station Station area area seeks seeks part part time time associate. associate. Experience Experience in in occlusion occlusion and and prosthodontics prosthodontics isis desired. desired. Email Email resume resume to to dentalpath2013@gmail.com. dentalpath2013@gmail.com.

DALLAS CARROLLTON, TOLLWAY TEXAS: &LBJ:Endodontist Dentists needed with advanced parttime endoand training full-time & Texas for new, dental extended-hours, license. Contacthigh production, HR info@texasendodontics.net treatment-oriented or practice mail to: opening Texas just Endodontics, prior to Memorial 2840 Keller Day.Springs Must be Rd comfortable #703, Carrollton, with TX 75006. most molar endo and wisdom tooth extraction cases. Implants experience a huge plus. Plenty of DALLAS TOLLWAY Dentists needed partC&B. Dentures also&LBJ: an opportunity.

1099 contract time andwith full-time for new, extended-hours, high position generous commission.

For immediate production, treatment-oriented opening consideration, please email yourpractice CV and availability just prior to Memorial Day. Must be comfortable to cv@erdentist.com. with most molar endo and wisdom tooth extraction DDR cases.DENTAL Implants- ODESSA: experience General a hugepractice. plus. Plenty Cosmetic of practice C&B. Dentures with high-6 also an figure opportunity. gross and1099 high contract net income. position Excellent with generous recall commission. program andFor stable immediate patient base. consideration, More than please 2,000email sq. ft.your using CVfour andoperatories availability (2 to dental cv@erdentist.com. and 2 hygiene), well maintained with latest equipment, digital x-ray and paperless charts.

DDR DENTAL ODESSA: General practice.

Cosmetic Contact Chrissy- Dunn at 800-930-8017 or visit www. practice with high-6 figure gross and high DDRDental.com (Seller is DDR Dental Trustnet Member) income. Excellent recall program and stable patient DDR base.DENTAL More than — NEAR 2,000 sq.

AUSTIN: ft. using Denture four operatories practice 20 miles fromand Austin with seven gross and (2 dental 2 hygiene), wellfigure maintained withvery, very net income.

Excellent referral program and latesthigh equipment, digital x-ray and paperless charts. employed denturist. office usingwww. five Contact Chrissy DunnWell-equipped at 800-930-8017 or visit operatories DDRDental.com (1 surgical (Sellersuite). is DDRWell-oiled Dental Trust machine Member) that still has growth potential. Contact Chrissy Dunn DDR DENTAL — or NEAR Denture practice 20 at 800-930-8017 visit AUSTIN: www.DDRDental.com (Seller Austin seven figure gross and very, ismiles DDRfrom Dental Trustwith Member). very high net income. Excellent referral program and

DDR employed DENTAL denturist.

— AUSTIN Well-equipped (South Lamar): officeGeneral using five practice.

Well(1established on South Lamar Blvd in operatories surgical suite).

Well-oiled machine Austin. traffic and booming Practice that stillVery has high growth potential.

Contactarea.

Chrissy Dunnin historic house that highly visible. Four operatories at 800-930-8017 orisvisit www.DDRDental.com (Seller in use, plumbed for Member).

1 more. Low-6 figure gross but a is DDR Dental Trust great patient base and growth opportunity. Building DDRavailable DENTALfor — sale.

AUSTIN (South Lamar): General also Contact Chrissy Dunn at 800practice. Well established on South Lamar Blvd in 930-8017 or visit www.DDRDental.com.

Austin. Very high traffic and booming area. Practice in DDR DENTAL NORTH HOUSTON: General historic house — that is highly visible. Four operatories practice.

Seven figure expected very but high-a in use, plumbed for 1 gross more.with Low-6 figure gross 6great figure net income.

Sixgrowth fully equipped operatories. patient base and opportunity.

Building Office inside professional building.

Hispanic and also available for sale. Contact Chrissy Dunnarea at 800Medicaid Contact Chrissy Dunn at 800930-8017accepted. or visit www.DDRDental.com.

930-8017 or visit www.DDRDental.com (Seller is DDR DDR DENTAL — NORTH HOUSTON: General Dental Trust Member). practice. Seven figure gross with expected very highDENTISTS: practiceSix of 1fully yearequipped looking for a BC/ 6 figure netAincome. operatories.

BE pediatric to come on board as employee Office insidedentist professional building.

Hispanic area and with possible buy-in.Contact This is an all pediatric Medicaid accepted.

Chrissy Dunn atdentists’ 800office.

Youor would working next to a BC pediatric 930-8017 visit be www.DDRDental.com (Seller is DDR dentist.

GoodMember). terms with great pay and work hours.

Dental Trust Must be able to get Board Certified within 1 year. OR DENTISTS: 1 year looking for aExcellent BC/ cases done Aatpractice El Paso’sofChildren’s Hospital.

BE pediatric dentist come on board as employee opportunity.

Contactto719-671-5617 or tparco@ with possible buy-in. This is an all pediatric dentists’ dentalquestions.com. office. You would be working next to a BC pediatric DFW dentist.

AREA: Good Seeking terms general with great dentists pay and andwork specialists. hours.

Our Mustoffices be able aretolocated get Board in the Certified Dallas /within Fort Worth 1 year. OR area. casesWe done areatlooking El Paso’s forChildren’s caring, energetic Hospital.associates.

Excellent New opportunity. graduateContact and experienced 719-671-5617 dentists or tparco@ welcome.

We dentalquestions.com. offer benefits, a helpful working environment and an opportunity to grow. We accept most DFW AREA: Seeking general dentists and specialists. insurance and Medicaid.

Please submit your resume Ouremail offices located in the Dallas / Fort Worth via to are jennifer@smileworkshop.com or call our area. We are looking for caring, energetic associates. office at 214-757-4500.

New graduate and experienced dentists welcome.

We offer benefits, a helpful working environment and an opportunity to grow. We accept most

Texas Texas Dental Dental Journal Journal ll www.tda.org www.tda.org ll February February 2015 2015

147 147

ADVERTISING BRIEFS insurance EAST TEXAS: andWell-established Medicaid. Pleasedental submit practice your resume seeks caring, via email proficient, to jennifer@smileworkshop.com and motivated dentist fororassociate call our employment. office at 214-757-4500.

Our office is located in a mid-sized town with abundant outdoor activities including EAST TEXAS: Well-established dental practice seeks hunting and fishing and a “small town” atmosphere. caring, proficient, motivatedInterested dentist for associate We offer all phasesand of dentistry. employment.

Our office located in a mid-sized candidates should email iscorrespondence and resume town with abundant outdoor activities including to mloon242@aol.com. hunting and fishing and a “small town” atmosphere.

We EDINBURG offer all phases — FALCON of dentistry.

DENTISTRY Interested PA dba Falcon Dental candidates Center should seeksemail dentist correspondence in Edinburg. Doctor and resume of Dental to mloon242@aol.com.

Surgery degree required. Texas dental license required. Qualified applications may submit resume EDINBURG — FALCON dba Falcon directly to Atlantis GloriaDENTISTRY Moya, officePAmanager, via Dental Center seeks dentist in Edinburg.

Doctor of fax at 956-287-4926 or via email at falcondentistry@ Dental Surgery degree required. Texas dental license gmail.com. required. Qualified applications may submit resume EL PASOto directly COUNTY: Atlantis General Gloria Moya, practiceoffice #TX-1179. manager,Four via operatories. fax at 956-287-4926 Beautiful, or recently via emailbuilt. at falcondentistry@ Well equipped.

Owner must sell (family relocation). 2014 collections gmail.com. projected at mid-low 6 figures. Price: $245,000.

EL COUNTY: #TX-1179.

Four ForPASO details contact General AmandapracticeChristy (NPT, LLC) 877operatories.

Beautiful, recently built. Well equipped.

365-6786 x230, a.christy@NPTdental.com or www.

Owner must sell (family relocation). 2014 collections NPTdental.com. projected at mid-low 6 figures. Price: $245,000.

EL PASO For details —contact GREAT DENTIST Amanda Christy TO WORK (NPT, WITH LLC)KIDS: 877Good opportunity 365-6786 x230, a.christy@NPTdental.com for someone who likes children. or www.

Busy practice. Great personality. Competent dentist NPTdental.com. not afraid to work. Great pay. Sedation taught. Send EL PASOASAP — GREAT DENTIST TO WORK WITH KIDS: resume to Carol Erickson, info@txkidsdental.

Good opportunity forAvenue someone likes children. com, 9411 Alameda Ste who P, El Paso, TX 79907.

Busy practice. Great personality. Competent dentist 602-309-2180. not afraid to work. Great pay. Sedation taught. Send EL PASO:ASAP resume Orthodontic to Carol Erickson, practice for info@txkidsdental. sale. Excellent location; com, 9411 successful Alamedapractice.

Avenue Ste Doctor P, El Paso, will transition.

TX 79907.

Very nice office. Whether a buyer or a seller, trust 602-309-2180. your life’s work to the most experienced senior appraiser/broker. For over 40 years, you have seen the name, Gary Clinton, appraiser, with the first 20

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Texas Dental Journal l www.tda.org l February 2015

EL PASO: practice for sale.

Excellent years as aOrthodontic dental consultant.

Buyers, avoid overlocation; practice.

Doctor will selling transition. payment successful for a practice and sellers, avoid Very office.

Whether a buyer or abuyers seller,are trust belownice market value.

Knowledgeable your life’s work toFair the Market most experienced seniorareas. willing to pay the Value in growth appraiser/broker.

For over years,comparables you have seen My certified appraisals use 40 market the Clinton, appraiser, with the first 20 fromname, TexasGary practices located all over Texas.

Senior years as a Member dental consultant.

Buyers,ofavoid overAppraiser of The Institute Business payment forInc. a practice and sellers, avoid selling Appraisers, Call Gary Clinton confidentially below market value. Knowledgeable buyers are 1-800-583-7765. willing to pay the Fair Market Value in growth areas.

FORT WORTH: Practice use for sale in the fast growing My certified appraisals market comparables Southwest Average gross; 6 operatories; from Texas area. practices located all over Texas. Senior Excellent lease.

Seller relocating. to move Appraiser Member of is The Institute Need of Business quickly on this DFWClinton 214-503-9696.

WATS 800Appraisers, Inc.one.

Call Gary confidentially 583-7765.

1-800-583-7765.

FORT WORTH: WORTH (SOUTH PracticeAREA): for saleGeneral in the fast practice growing for sale. Well-established family6practice.

With Southwest area. Average gross; operatories; excellent,lease. solid recall. transition or outright Excellent Seller isWill relocating.

Need to movesale. quickly Excellent onwell-trained this one. DFW staff.214-503-9696.

6 equipped operatories.

WATS 800583-7765.

Mostly fee-for-service with no plans Gorgeous office to purchase or lease. Whether a buyer or a seller, FORT WORTH General practicesenior for trust your life’s(SOUTH work toAREA): the most experienced sale.

Well-established family with excellent, appraiser/broker.

For over 40practice. years, you have seen solid recall.Gary WillClinton, transition or outright the name, appraiser, withsale. the Excellent first 20 well-trained staff.consultant.

6 equippedBuyers, operatories.

Mostly years as a dental avoid overfee-for-service with no and planssellers, Gorgeous to payment for a practice avoidoffice selling purchase or lease.

Whether a buyer or a seller, below market value.

Knowledgeable buyers aretrust your life’s work toFair the Market most experienced seniorareas. willing to pay the Value in growth appraiser/broker.

For over years,comparables you have seen My certified appraisals use 40 market the Clinton, appraiser, with the first 20 fromname, TexasGary practices located all over Texas.

Senior years as a Member dental consultant.

Buyers,ofavoid overAppraiser of The Institute Business payment forInc. a practice and sellers, avoid selling Appraisers, Call Gary Clinton confidentially below market value. Knowledgeable buyers are 1-800-583-7765. willing to pay the Fair Market Value in growth areas.

GARLAND: My certifiedEquipped appraisals dental use market office for comparables lease. from Texas practices locatedDental all over Texas.

Senior Downtown Garland, Texas. office, 4 ops, Appraiser Member The Institute of Business chairs, pano, digitalof scanner, x-ray unit, etc. Available Appraisers, Inc.release.

Call Gary Clinton for immediate Please callconfidentially 214-415-9096.

1-800-583-7765.

ADVERTISING BRIEFS GARLAND: Equipped GEORGETOWN: Are you dental looking office forfor a position lease. where you can practice Downtown Garland, highTexas. quality Dental dentistry? office,If4so, ops, this may be yourpano, chairs, spot.digital We arescanner, lookingx-ray for a unit, friendly etc.dentist Available to joinimmediate for our Belton,release.

Texas practice.

Please call If interested, 214-415-9096. please send your resume to qualitydentalassociate@gmail.

GEORGETOWN: Are you looking for a position where com. you can practice high quality dentistry? If so, this may GUN be your BARREL spot. We CITY:are East looking Texasfor 2-operatory, a friendly dentist to standalone dental office.

1200 sq ft remodeled join our Belton, Texas practice.

If interested, please home.your send All removable resume to qualitydentalassociate@gmail. prosthetic practice. All fee-forservice. Mid-6 figure income. 12 hours per week com. schedule. Growth potential for general dentistry and GUN BARREL CITY: East to Texas 2-operatory, implants.

Doctor wants retire and travel. Contact standalone dental office.

1200 sq ft remodeled 903-432-9414 in the evenings. home. All removable prosthetic practice. All fee-forHILL COUNTRY: Oral surgery Sale: Great service.

Mid-6 figure income.practice 12 hoursforper week place to raise a family.

Veryfor successful schedule.

Growth potential general practice. dentistry and Outright sale transition.

High net.and Only basicContact routine implants.

Doctor wants to retire travel. treatment. Area an oral surgeon interested 903-432-9414 in needs the evenings. in extensive oral surgery care. This is a golden HILL COUNTRY: Oral surgery practice for Sale: opportunity.

Whether a buyer or a seller, trust Great your place to raise a family.

Very successful practice. life’s work to the most experienced senior appraiser/ Outright saleover transition.

High Only basic broker. For 40 years, younet. have seen the routine name, treatment.

Area needs an oralthe surgeon Gary Clinton, appraiser, with first 20interested years as a in extensive oral surgery This is a golden for a dental consultant.

Buyers,care. avoid over-payment opportunity.

Whether a buyer or below a seller,market trust your practice and sellers, avoid selling value. life’s work to thebuyers most experienced appraiser/ Knowledgeable are willing tosenior pay the Fair broker.

For over 40 years, you My havecertified seen the name, Market Value in growth areas. appraisals Gary Clinton, appraiser, with firstpractices 20 years located as a use market comparables fromthe Texas dental Buyers, avoidMember over-payment all overconsultant.

Texas. Senior Appraiser of Thefor a practice sellers, avoid sellingInc. below value.

Institute and of Business Appraisers, Callmarket Gary Clinton Knowledgeable buyers are willing to pay the Fair confidentially 1-800-583-7765.

Market Value in growth areas. My certified appraisals HOUSTON use marketAREA comparables PRACTICE: from JeffTexas Jones, practices DDS, located HS over all Professional Texas. Senior Practice Appraiser Transitions.

Member Excellent of The opportunity Institute of Business to capitalize Appraisers, on a fully Inc.digital Call Gary high Clinton tech practice. Highly confidentially 1-800-583-7765. visible location with a great lease.

Beautiful finish out includes 5 chairs with room for expansion. Impressive new patient flow with

HOUSTON AREA PRACTICE: Jones, DDS,in high 6 strong hygiene revenue and Jeff gross receipts HS Professional Practice Excellentneeded. figures.

Owner willing toTransitions. stay on as associate opportunity to contact: capitalizeJeff onJones, a fully DDS, digitalwith highHStech To learn more, practice.

Highly visibleTransitions location with a great lease.

Professional Practice 830-832-5522, or Beautiful finish out includes 5 chairs with room dr.jeff.jones@henryschein.com. for expansion. Impressive new patient flow with HOUSTON: GREAT OPPORTUNITY FOR SPECIALIST: strong hygiene revenue and gross receipts in high 6 An endodontic southwest Houstonneeded. figures.

Owner practice willing toinstay on as associate is seeking to share spaceJeff with a part or full To learn more, contact: Jones, DDS, withtime HS periodontist,Practice Professional oral surgeon Transitions or orthodontist 830-832-5522, in a state or of the art dental office. 4 operatories fully equipped dr.jeff.jones@henryschein.com. with digital X-rays and microscope. For more HOUSTON: OPPORTUNITY FOR SPECIALIST: information,GREAT contact 713-932-1913.

An endodontic practice in southwest Houston HUMBLE: Dental, in Austin, is seeking Carus to share spaceestablished with a partinor1983 full time TX, has alwaysoral been committed to the traditional periodontist, surgeon or orthodontist in a state doctor-patient relationship and to thefully highest quality of the art dental office. 4 operatories equipped in dental with digital care X-rays and and service. microscope.

We currently For more have 55 doctors on staff information, contact across 713-932-1913. our 21 practices in Austin, Houston and central Texas. We offer dental services HUMBLE: Dental, in 1983 in Austin, in general Carus dentistry, oralestablished surgery, orthodontics, TX, has always beenendodontics, committed toand theperiodontics traditional in pediatric dentistry, doctor-patient relationship highest quality some or all of our practices.and Weto arethe seeking partin dental care andfor service.

We currently 55 time endodontist our Humble, Texas,have practice, doctors on staff across ourTo21learn practices Austin, 3 days every other week. more in about Houston central Texas.and WeCarus offer dental Americanand Dental Partners Dental services please in general dentistry, oral surgery, orthodontics, visit us at www.amdpi.com and www.carusdental. pediatric dentistry,please endodontics, com. If interested, send CVand andperiodontics cover letterin to some or all of our practices. We are seeking partkateanderson@amdpi.com. time endodontist for our Humble, Texas, practice, KILLEEN, 3 days every ENDODONTIST other week.— ToFULL learnTIME: more Carus about Dental, established American Dental Partners in 1983and in Austin, Carus Dental has always please beenus visit committed at www.amdpi.com to the traditional and www.carusdental. doctor-patient relationship com.

If interested, and toplease the highest send CV quality and in cover dental letter care to and service. We currently have approximately 48 kateanderson@amdpi.com. doctors on staff across our 21 practices in Austin, KILLEEN, ENDODONTIST — We FULLoffer TIME: Carus Houston and Central Texas. dental services Dental, established 1983 in Austin, has always in general dentistry,inoral surgery, orthodontics, been committed to endodontics, the traditionalperiododontics doctor-patientand pediatric dentistry,

Texas Dental Journal l www.tda.org l February 2015

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ADVERTISING BRIEFS relationship andintosome prosthodontics the highest or all ofquality our practices. in dentalCarus care Dental and service. has been We accredited currently have by the approximately Accreditation 48 Association doctors on staff of Ambulatory across our Health 21 practices Care since in Austin, 2000.

We offer and Houston a competitive Central Texas. salary Weand offer excellent dental benefit services package in generalincluding dentistry, a 401k, oral surgery, health insurance orthodontics, and a professional pediatric dentistry, work environment. endodontics,To periododontics learn more about and American DentalinPartners prosthodontics some orand all ofCarus our practices.

Dental please Carus visit us has Dental at www.amdpi.com been accredited and by the www.carusdental.

Accreditation com. If interested, Association of Ambulatory please send Health CV Care and cover since letter 2000. to kateanderson@amdpi.com.

We offer a competitive salary and excellent benefit package including a 401k, health insurance and a LUBBOCK: Fee-for-service practice for about professional work environment.

To looking learn more an associate dentist to provide patient care as American Dental Partners and Carus Dental please well us as build their own patient 4 days per visit at www.amdpi.com andbase. www.carusdental. week Ifand possible please future ownership opportunity. com. interested, send CV and cover letter to Experience in extractions, root canal therapy, and kateanderson@amdpi.com. implants preferred. Please send CV to toothmom@ kathleennicholsdds.com.

LUBBOCK: Fee-for-service practice looking for an associate dentist to provide patient care as NEWasCANEY: Associate pediatric dentist â&#x20AC;&#x201D; New well build their own patient base.

4 days per Caneyand Texas.

Exceptional in a wellweek possible future opportunity ownership opportunity. established in practice for a career oriented pediatric Experience extractions, root canal therapy, and dentist. The primaryPlease dentistsend enjoys excellent implants preferred.

CV an to toothmom@ reputation and has a long-standing history of kathleennicholsdds.com. providing quality pediatric dentistry while building long term trusting relationships families.

Our NEW CANEY: Associate pediatricwith dentist â&#x20AC;&#x201D; New familiesTexas.

Caney expect Exceptional a pediatricopportunity dentist thatinisaenergetic, wellhighly professional, established practicewith for aacareer strongoriented compassionate pediatric demeanor. practice owner seeks like-minded dentist.

TheThe primary dentist enjoys anaexcellent associate pediatric who genuinely reputation and has dentist a long-standing historyisof transparent providing quality and holds pediatric integrity dentistry with while the highest building regard.

Thetrusting practice offers an excellent compensation long term relationships with families.

Our package expect with a possible future equity Please families a pediatric dentist thatposition. is energetic, email serious highly professional, inquires with with a strong contact compassionate information and C.V. to newcaneypedodontist@gmail.com demeanor.

The practice owner seeks a like-minded No corporations please.dentist who genuinely is associate pediatric transparent and holds integrity with the highest regard. The practice offers an excellent compensation package with a possible future equity position. Please

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Texas Dental Journal l www.tda.org l February 2015

OPPORTUNITY TO TRANSITION A BUSY email serious inquires with contactINTO information ORAL SURGERY PRACTICE within a multi- No and C.V. to newcaneypedodontist@gmail.com disciplined practice. corporations please. Present oral surgeon is retiring.

Practice is private fee-for-service. New i-CAT (3D) in office.

OPPORTUNITY For information TO TRANSITION contact PaulINTO Kennedy, A BUSY DDS at pkennedy@gte.net ORAL SURGERY PRACTICE or 361-960-6484. within a multidisciplined practice. Present oral surgeon is retiring.

PRACTICE We are New a Texas-based Practice is OPPORTUNITY: private fee-for-service. i-CAT (3D) in family group dental practice serving patients of all at office.

For information contact Paul Kennedy, DDS ages. With a busy workload and high traffic, our pkennedy@gte.net or 361-960-6484. needs extend to general dentists, orthodontists, pediatric dentists, PRACTICE OPPORTUNITY: and endodontists.

We are a Texas-based Qualified, compassionate family group dental and motivated practice serving doctors patients interested of all in opportunities ages.

With a busytoworkload provide high and quality high traffic, care our in communities may contactorthodontists, us. Our offices needs extend in toTexas general dentists, provide: State of the high-tech facility; in-house pediatric dentists, andart, endodontists.

Qualified, digital X-rays; paperless charting; 3-D models; digital compassionate and motivated doctors interested tracing and imaging.

Work alongside in-house in opportunities to provide high quality care in board certified dentists, surgeons, communities inpediatric Texas may contactoral us. Our offices endodontists general dentists, facility; allowingin-house one to provide: Stateand of the art, high-tech provideX-rays; the absolute best care possible to evendigital the digital paperless charting; 3-D models; most challenging cases.

To alongside join our team, please tracing and imaging.

Work in-house forward board certified your CVpediatric to tx.dentistrygroup@gmail.com. dentists, oral surgeons, endodontists and general dentists, allowing one to PROSPER-CELINA AREA: year family provide the absolute bestFourteen care possible to even the practice available cases. in Prosper-Celina area. Dentist most challenging To join our team, please retiring from practice. docjwf@hotmail.com forward your private CV to tx.dentistrygroup@gmail.com.

RIO GRANDE VALLEY: A well-established, privately PROSPER-CELINA AREA: Fourteen year family owned Harlingen seeks experienced dentist practice available practice in Prosper-Celina area. Dentist associate to work 3-4practice. days a week.

Our new location retiring from private docjwf@hotmail.com offers 4 state-of-the-art equipped operatories withGRANDE RIO 3 available VALLEY: to expand.

A well-established, We focus on delivering privately quality dentistry owned Harlingeninpractice a friendly, seeks relaxing experienced environment. dentist Excellent production associate to work 3-4and daysearning a week.potential Our new location with the offers 4 state-of-the-art opportunity to equipped grow withoperatories the practice.

Please with 3 available email cover to expand. letter and We resume focus on to office@ delivering valleyfamilydentistry.org. quality dentistry in a friendly, relaxing environment.

Excellent production and earning potential

ADVERTISING BRIEFS with ANTONIO SAN the opportunity â&#x20AC;&#x201D; EXCELLENT to grow with FULL-TIME the practice.

POSITION: Sherri L.email Please Henderson cover letter & Associates, and resume LLCto is looking office@for a qualified general dentist to transition into an active valleyfamilydentistry.org. family and cosmetic practice in the Alamo Heights SAN EXCELLENTthe FULL-TIME area.ANTONIO The ownerâ&#x20AC;&#x201D;established practice POSITION: in 1980.

Sherri L. Henderson & Associates, LLCannually is looking The practice produces seven figures andfor a qualified general dentist to high transition an active is dedicated to performing qualityinto dental care family and of cosmetic practice incommunities. the Alamo Heights to families the surrounding The area.

Theisowner established practice in 1980. practice currently 2,115 sq the ft with four treatment The practice figuresinto annually and rooms and isproduces capable ofseven expanding an additional is dedicated high quality dental is care 1,300 sq ft intoanperforming adjoining space.

The position for to families of the surrounding a full-time, experienced dentistcommunities. who will haveThe the practice is currently 2,115 sq ft with fournear treatment opportunity to become a partner in the future. rooms expanding into an additional He/sheand willisbecapable workingofwith a very dedicated and 1,300 sq ft in anteam. adjoining space. The position is and for knowledgeable Compensation, insurance abenefit full-time, experienced dentist will have the plans are negotiable.

Forwho more information, opportunity to our become partner in the near future. please contact officea at 972-562-1072, email He/she will be working with or a very and sherri@slhdentalsales.com, visit dedicated our website at knowledgeable team. Compensation, www.slhdentalsales.com.

Photos and ainsurance practice and benefit plans are negotiable. more #3015. information, overview are available.

Refer For to listing please contact our office at 972-562-1072, email SAN ANTONIO NORTH WEST: sherri@slhdentalsales.com, orAssociate visit our website needed.at Established general dentalPhotos www.slhdentalsales.com. practice and seeking a practice quality oriented associate. overview are available.

NewRefer graduate to listing and #3015. experienced dentists welcome. GPR, AEGD preferred. Please SAN ANTONIO NORTH Associateorneeded. contact Dr Henry Chu atWEST: 210-684-8033 Established general dental practice seeking quality versed0101@yahoo.com. oriented associate. New graduate and experienced dentists welcome.

GPR, AEGD preferred.

Please SAN ANTONIO: A general practice (FFS/PPO) having gross receipts contact Dr Henry in mid Chu6atfigures 210-684-8033 while practicing or only versed0101@yahoo.com.

3.5 days per week with no marketing. This is an exceptional opportunity to profit from day one in a SAN A general practice with (FFS/PPO) having newlyANTONIO: remodeled office equipped 3 chairs for gross receipts in cost mid 6offigures practicing only a fraction of the a new while start up.

Tremendous 3.5 days per weekpractice with no rapidly marketing.

This is dentist an potential to grow as current exceptional opportunity to profit daypedo, one in a refers out majority of endo, ortho,from perio, and newly remodeled equipped with 3this chairs for oral surgery cases.office To learn more about practice acontact: fractionDr ofJeff the Jones, cost of830-832-5522 a new start up./ Tremendous dr.jeff. potential to grow practice rapidly as current dentist jones@henryschein.com.

refers out majority of endo, ortho,dentist perio, pedo, and SAN ANTONIO: Associate general needed oral cases.

To learn moreand about this practice for asurgery full-time position in a new growing office contact: DrofJeff Jones, 830-832-5522 / opportunity dr.jeff. located off TPC Parkway.

An Amazing jones@henryschein.com. for growth in this community. Would prefer a doc with at least 2 years experience but not required.

SAN ANTONIO: Associate general We are equipped with digital xrays,dentist pano, needed intra-oral for a full-time position in a newopening and growing office camera, tv in ops.

Immediate is available. located of TPC Parkway.

Amazing opportunity Contact:off Please forward CV An to sonya@tpcdentalcare. for growth in this community. Would prefer a doc com; 210-705-9297. with at least 2 years experience but not required.

We arePRACTICE equipped TRANSITIONS, with digital xrays, TEXAS INC.pano, Rich intra-oral Nicely has camera, tv in Texas ops. Immediate opening available. been serving dentists since 1990.isVisit www.

Contact: to sonya@tpcdentalcare. tx-pt.comPlease or callforward at (214)CV 460-4468; Rich@tx-pt.com. com; 210-705-9297.

NORTH OF HOUSTON: Medium sized full fee patient base; Digital x-rays; Free standing building; long TEXAS PRACTICE Rich Nicely has term staff; 4 days TRANSITIONS, of hygiene per INC. week.

EAST TEXAS: been serving since 1990.

Visit www.

Medium sizedTexas PPO dentists patient base.

Free standing. tx-pt.com call at 214-460-4468; VICTORIA:orMedium sized practice;Rich@tx-pt.com.

PPO patient NORTH OFstanding HOUSTON: Medium sized fullstaff; fee patient base; free building, long term doctor base; Free standing building; longLarge refers Digital out lotsx-rays; of dentistry.

EL PASO: East side; term staff;full 4 days of hygiene practice; fee patient base.per EL week.

PASO: EAST West TEXAS: side; Medium PPO patient base.

Free standing. medium sized practice; mostly PPO patient base.

VICTORIA: sized practice; PPO patient BEAUMONT:Medium Medium sized PPO practice; very nice base; free standing building, staff; doctor free standing building, 5 ops.long SANterm ANTONIO: Very refers out lots of implant dentistry.

EL PASO: side; Large large, high-tech, focused, fullEast fee restorative practice; full fee patient base.

EL PASO: West practice with 7 equipped treatment rooms in side; a highly medium sized practice; mostlywith PPOdigital patient base.a visible free standing building x-rays, BEAUMONT: Medium practice;scanner. very nice cone beam x-ray and a sized digitalPPO impression free building, ops.ofSAN ANTONIO: Very Longstanding term staff and 10 5days hygiene per week. large, high-tech, implant full fee restorative The doctor desires to sellfocused, half the practice now and practice treatment rooms in DALLAS a highly the otherwith half7inequipped 5 years prior to retirement. visible freeMedium standingsized building digital x-rays, a SUBURB: PPO with practice, 5 treatment cone beam x-ray and aHighly digitalvisible impression scanner. rooms, digital x-rays. retail location.

Long term staff and 10 days of hygiene per week.

The doctor desires to sell half the practice now and the other half in 5 years prior to retirement. DALLAS SUBURB: Medium sized PPO practice, 5 treatment rooms, digital x-rays. Highly visible retail location.

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ADVERTISING BRIEFS TEXAS: ResiDental Associates is now hiring dentists and hygienists around the state of Texas for skilled nursing home practice. Wonderful schedules, very competitive pay, rewarding cases. These locations are EVERYWHERE in the state. Our patients need you!

Please send resume to Leah@residental.com or fax 817-589-9037. Office phone 817-589-7374.

TYLER, ASSOCIATE FOR GENERAL DENTISTRY PRACTICE: Well-established general dentist in Tyler with over 34 years experience seeks a caring and motivated associate for his busy practice. This practice provides exceptional dental care for the entire family. Our office is located in beautiful east Texas and provides all phases of quality dentistry in a friendly and compassionate atmosphere. The practice offers a tremendous opportunity to grow.

The practice offers excellent production and earning potential with a possible future equity position available. Our knowledgeable staff will support and enhance your growth and earning potential while helping create a smooth transition. Interested candidates should call 903-509-0505 and/or send an email to steve.lebo@sbcglobal.net.

WACO: Great associate opportunity. Waco practice looking for motivated associate with a desire to join a PPO/fee-for-service practice. Great pay, great work environment with 2 other dentists and top notch staff. Please contact Dr Johnson at 435-237-2339 or email at johnson.2978@gmail.com.

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OFFICE SPACE DALLAS/FORT WORTH DENTAL PRACTICE OPPORTUNITIES: Lewis Health Profession Services has multiple career opportunities available in the North Texas area. Practices for sale, associate opportunities, finished out dental offices, and specialty practice opportunities available. Lewis Health Profession Services has 30 years experience in dental practice transitions, with over 1,000 successful transitions completed. Dentistry is our only business.

We confidentially deal with all clients. Lewis Health Profession offers seller representation, buyer representation, opportunity assessments, associate placement and strategic planning services. Please check out our website at www.lewishealth.com for current opportunities. For additional information, contact Dan Lewis at Lewis Health Profession Services 972-437-1180 or dan@lewishealth.com.

DALLAS: Office space for lease, Dallas, Lake Highland area, 2,600 sq ft 5 op, beautiful office. For details contact ziaasma2@yahoo.com.

GROVES/GOLDEN TRIANGLE AREA: Dental office building for sale or lease. Approximately 1,500 sq ft with brick exterior. Plumbed for four operatories.

Three operatories are fully equipped with chairs, cabinetry, and X-ray machines. Excellent condition and move-in ready. Call 409-728-3565 or email mvsv123@aol.com.

ADVERTISING BRIEFS FOR SALE EQUIPMENT FOR SALE: New handheld portable X-ray unit. New intraoral wall X-ray unit, new mobile X-ray on wheels. New chairs/units operatory packages, new implant motors. Everything is brand new, with warranty. Contact nycfreed@aol.com.

INTERIM SERVICES HAVE MIRROR AND EXPLORER, WILL TRAVEL: Sick leave, maternity leave, deployment, vacation or death, I will cover your office. Call Robert Zoch, DDS, MAGD at 512-263-0510 or drzoch@yahoo.com.

MISCELLANEOUS HANDS ON EXTRACTION CLASSES: Learn advanced extraction techniques, elevating flaps, suturing, third molar removal, sinus perforation closure, using instruments properly and how to handle large abscesses and bleeding. Classes combine lecture and participation on live patients. Website: www. weteachextractions.com Phone: 843-488-4357 Email: drtommymurph@yahoo.com.

LOOKING TO HIRE A TRAINED DENTAL ASSISTANT? We have dental assistants graduating every 3 months in Dallas and Houston. To hire or to host a 32-hour externship, please call the National School of Dental Assisting at 800-383-3408; Web: schoolofdentalassisting-northdallas.com.

PLACE A CLASSIFIED AD IN THE

TEXAS DENTAL JOURNAL Itâ&#x20AC;&#x2122;s a member benefit!

Reach more than 9,000 of your dental colleagues.

COST

PRINT: $60 for the first 30 words for ADA members. $80 for the first 30 words for non-ADA members. 10 cents per word after that.

ONLINE: $10 a month (no word limit). $60 one-time additional fee to post online immediately.

CONTACT

For more information, please visit tda.org or contact Hannah Atteberry at 512-443-3675 ext 124, or by email: hannah@tda.org.

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YOUR PATIENTS TRUST YOU.

WHO CAN YOU TRUST?

ADVERTISERS ADS Watson Brown & Associates Associates.......................121 ......................121 AFTCO......................................................................97 AFTCO .....................................................................97 AJ Riggins Riggins..............................................................145 .............................................................145 Anesthesia Education & Safety.............................94 Clinton, Gary Gary..........................................................110 .........................................................110 DDR Dental Trust Trust...................................................143 ..................................................143 Dental Credentialing of Texas Texas..............................131 .............................131 Dental Handpiece Repair Guy Guy..............................130 .............................130 Dental Post Post.............................................................131 ............................................................131

If you or a dental colleague are experiencing impairment due to substance use or mental illness, The Professional Recovery Network is here to provide support and an opportunity for confidential recovery.

Dental Systems Systems....................................................... .................................................... 111 E-VAC, Inc. Inc..............................................................135 ............................................................135 Law.................................140 Hanna, Mark â&#x20AC;&#x201D; Attn. at Law ................................140 Henry Schein.........................................................121 Group........................................................131 .......................................................131 Hindley Group JKJ Pathology.........................................................99 PLLC...................137 Kennedy, Thomas John, DDS, PLLC ..................137 Protective...................................................95 Medical Protective ..................................................95 Paragon..................................................................135 Paragon .................................................................135 Associates...............................................141 Phase II Associates ..............................................141 Professional Recovery Network..........................154 Solutions..........................................109 .........................................109 Professional Solutions Wilson........................................122 Shepherd, Boyd Wilson .......................................122 Associates.........................91 Sherri L. Henderson & Associates ........................91 TDA Financial Services Insurance Program Program.......................................... ......................................... 110/Back Cover TDA.org........................................

MASA ........................................... Inside Back Cover TDA Perks Program.

Program .....................Inside ...................Inside Front Cover Texas Dental Journal Classifieds.

Classifieds........................157 ........................157 TEXAS Meeting Meeting......................................................101 .....................................................101

PRN Helpline (800) 727-5152

Visit us online www.txprn.com

TopProDeals TopProDeals...........................................................123 ..........................................................123 University of Texas School of Dentistry Dentistry.............. ............. 111 Waller, Joe Joe................................................................99 ...............................................................99

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